HomeMy Public PortalAbout10703 MILOANN ST_Mechanical__ i
WORKERS'COMPENSATION DECLcafe of corse APPLICATION FOR PERMIT
I hereby affifm that I have a certificate of consent to self ,
insure, or a certificate of Workers'Compensation Insurance, 'HEATING VENTILATING - AIR CONDITIONING
or a certified copy they Qfjf(Sec. 3800, Lob.-C.) 76A364C
��� � i.�} \ CE-818(REV. 10/81) '
Policy No. `� @@ ompany i LL
Certified copy is hereby.furnished. Y1114a, COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING
tion department. J (PRINT OR TYPE ONLY). ADDRESS ,100— .
Date .s—21— Applicant " ' `z - LOCALITY
� NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCECROSS ST. �'
(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.) I AIR HANDLING UNIT,CFM
I certify that in the performance of the work for which this t9
permit is issued, I shall not employ any person in any manner BOILER,BTU
so as to become subject to the Workers'Compensation LOWS. I APPROVALS DATE INSPECTOR'S SIGNATURE
1 ` COMPRESSOR,BTU ° ROUGH
Date Applicant i
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL .2
Exemption, you should become subject to the Workers'
Compensation provisions of-the Labor Code, you,must forth-' EVAPORATIVE COOLER VALIDATION
with comply with such provisions or this permit shall be
deemed revoked. FURNACE- FAU GRAVITY a
LICENSED,CONTRACTORS DECLARATION FLOOR BTU of
I hereby affirm that I am licensed under provisions bf Chapter 9 I HEATER: SUSPENDED UNIT '
'(commencing with Section 7000)of Division 3 of the Business I WALL
and Professions Code,and my license is'in full force and effect. IL
Z
License Number �' �? Lic. Class ' '� ► +1: O
Contractor'`'N !Y' 6 Date 5 ' l _ ! '#;: O'
❑ I am exempt under Sec. !� 1�t .- iel_ e�5
Plan check fee . ..+ d
B.BP.C. for this reason' F" `f 'z
`.:ly-3_45 in
PERMIT ISSUING FEE$. A# rt °r ILI—
5 •.HA GE
Date: s
TOTAL FEE /� a
Signature ,
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANTinq -+r I
I hereby affirm that I am exempt from the Contractor's License ► ''='`
Law for the following reason (Section 7031:5, Business and NAME ,',f-; a hh^i!°• i?'
Professions Code): _
El .1, as owner of the property, or my employees with ADDRESS i
wages as their sole compensation,will do the work and CITY TEL. NO.
the structure is not intended or offered for sale(Section
7044, Business and Professions Code). OWNER
El1, 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 eONTRACTOR
(Sec. 3097, Civ. C.).
' ADDRESS ?0
Lender's Name `f
Lender's Address CITY -L Z TEL. NO.35�
STATE 32 b� �Q
I certify that I have read this application and state that the LICENSE NO. CLASS ASS _
above information is correct. I agree to comply with all County
ordinances and State laws relating to building construction;
and hereby aut ize representatives of this County to enter
U;
he ab ov - len' red property for inspection purposes. ' . SEE REVERSE FOR EXPLANATORY LANGUAGE
—2
Signature o pfcant or Agent Date