Loading...
HomeMy Public PortalAbout5028 MCCLINTOCK AVE_Mechanical__ I>� WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT kbereby-affirm that I have a certificate of consent to self insure, or a certificate of Workers'Compensation Insurance, 76A364C HEATING - VENTILATING - AIR CONDITIONING or a 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 Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING ADDRESS tion department. i (PRINT OR TYPE ONLY) j- J Date Applicant I NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY ,1 v CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST COMPENSATION INSURANCE CROSS ST. Jr BTU DISTRICT NO. PROCESSED BY (This section need not be completed if the work involved by ABSORPTION UNIT, y� /� •�\-��f the permit Is for one hundred dollars($100)or less.) l AIR HANDLING UNIT,CFM f!�1©0 V J t(J I certify that in the per or n work for which this permit is issued, I shall n e ploy any pe on in any manner I BOILER, BTU so as to become subject to Workers' a cation Laws. APPROVALS DATE I SPE OR'S SIGNA RE I „ „ ` COMPRESSOR, BTU (!� ROUGH Date Applicant NOTICE TO APPLICANT: If, after m his C ificate of VENTILATION SYSTEM FINAL Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATI N with comply with such provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY LICENSED CONTRACTORS DECLARATION FLOOR BTU I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: 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 119� Contractor Date �950, 1 A u ❑ I am exempt under Sec. # 0 0 0 0 0 $ Plan check fee H B.&P.C. for this reason, PERMIT ISSUING FEE$ U S l o - 4275 Date: Signature TOTAL FEE , OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT o o 0 4 2 7 5'r�! I hereby affirm that I am exempt from the Contractor's License , Law for the following reason (Section 7031.5, Business and NAME O 5 0 2—$$ Profe ons Code): ADDRESS yz.: W7 as owner of the property, or my employees with wages as their sole compensation,will do the work and CITY TEL. NO. the structure is not intended or offered for sale(Section 1 7044, Business and Professions Code). OWNER' rC ' 1 ❑ I, as owner of the property, am exclusively contracting MAIL with licensed contractors to construct the project (Sec- ADDRESS 7 C tion 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY CITY TEL. NO. CJ _ I DV 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 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 r inan and State laws relating to building construction, andatheo ize representatives of this County to enter upntioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signnt or ent Dote