HomeMy Public PortalAbout4904 MCCLINTOCK AVE_Mechanical__ 'WORKERS'COMPEaSATION DECLARATION APPLICATION FOR 'PERMIT
a I herffirm that I have a certificate of consent to self
Vhsur j, or a certificate of Workers'Compensation Insurance, 76A364C HEATING - VENTILATING - AIR CONDITIONING
ct(pb certified copy thereof(Sec. 3800, Lab. C.) CE-818(REV. 10/81)
Policy No. Company
Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
r_1 Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING f '� ��
tion department. (PRINT OR TYPE ONLY) ADDRESS
Date Applicant LOCALITY C
NO. TYPE OF APPLIANCE OR EQUIPMENT. FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST. r. (�Q
(This section need not be completed if the work involved by ABSORPTION UNIT,BTU DISTRICT NO, PROCESSED BY
the permit is for one hundred dollars($100)or less.)
AIR HANDLING UNIT,CFM
I certify that in the performance of the work for which this
permit is issued,I shall not employ any person in any manner
so as to beC6 Be s bleat to the Worker 'Compensation Laws. BOILER,BTU APPROVALS DATE IN yCTOR SIGNATURE
Date D "_ pplicant O� `� 'fti COMPRESSOR, BTU (4� 06 VV ROUGH i f .
NOTICE TO APPL CANT: If, aft making this Certificate of VENTILATION SYSTEM FINAL ,
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATICIIN
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU_I—GRAVIT O
LICENSED CONTRACTORS DECLARATION FLOOR BTU 71
I hereby affirm that I am licensed under provisions of Chapter 9HEATER: SUSPENDED UNIT
'(commencing with Section 7000)of Division 3 of the Business WALL
and Professions-Code,and my license is in full force and effect. �
0
License Number Lic. Class , V
Contractor Date
II—
U
❑ 1 am exempt under Sec. W
Plan check fee tZ
B.&P.C'for this reason' H
Date:
PERMIT ISSUING FEE$ 1 (1117-88
•.° I TOTAL FEE ;2091.9A
Signature '
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
law
affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and NAME LI 5 ��i�. I ° - 3Q50
Professions Code): _I/
ADDRESS ek ° ° ° 3 Q 5'0
El • I, as owner of the property, or my employees with � f ,
Wages as their'sole compensation,will do the work and CIS, TEL. NO. 10. 17'-88
the structure is not intended or offered for sale(Section L���
7044, Business and Professions Code).
OWNER Lela— ems.
I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec- MAIL
tion 7044, Business and Professions Code). ADDRESS
CONSTRUCTION LENDING AGENCY CITY TEL. NO.
I hereby affirm that'there is a construction lending agency for , }
the performance of the work for which this permit is issued CONTRACTOR
(Sec. 3097, Civ. C.).
ADDRESS '
Lender's Name
CITY UV TEL. NO.
Lender's Address STATE LIC.
I certify that I have read this application and state that the LICENSE NO. CLASS
above information is correct. I agree to comply with all County
ordinances and State laws relating to building construction,
and h authorize representatives of this County to enter
up n above-menti d property for inspection urpos s. SEE REVERSE FOR EXPLANATORY LANGUAGE
64
gn°ture of Applicant or Agent D to
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