HomeMy Public PortalAbout5802 MUSCATEL AVE_Mechanical__ WOrm th' I hrivNSATION DECLARATION APPLICATION FOR PERMIT
r,reby affirm that I have a.certificate of consent to selfOr a certificate of Workers'Compensation Insurance, FIEATING - VENTILATING - AIR CONDITIONING
ified copy thereof(Sec. 3800, Lab. C.) CE-81 C
CE-818(REV. 10/81)
Poli No.FaS41 Aa Company F_a O,,mA
ertified 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
C �
ADDRESStion department. &,o .f r S
(PRINT OR TYPE ONLY)
Date1' /eOhMi $ Q c)• IU
&?-Applicant .� DS LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE C
CERTIFICATE OF EXEMPTION FROM WORKERS' I NEAREST
COMPENSATION INSURANCE CROSS ST.
(This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO PROC766
Y
the permit is for one hundred dollars($100)or less.)
AIR HANDLING UNIT,CFM ``7 ezz_�I certify that in the performance of the work for which this t
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws. BOILER, BTU APPROVALS DATE INSPE T6R'S 5 ATURE
Date pplicanf Lie COMPRESSOR,BTU ROUGH
NOTICE TO APPLICANT: If, after Gaking this CertificatY of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers' --
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATPGNN
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT 1 J
(commencing with Section 7000) of Division 3 of the Business 1 WALL c / (J
and Professions Code,and my license is in full force and effect.
License Number 3119 9� Lic. Class.G.'-;A Q �
Contractor 4 5 Date J 1 A
❑ �.` o o c 0 o 08 �
I am exempt under Sec. Plan check fee 1 . 0 20. 0 �
n •
B.&P.C. for this reason c � � T �
PERMIT ISSUING FEE$
Date:
Signature TOTAL FEE 7
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and NAME
Professions Code):
❑ I, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the wofk and
the structure is not intended or offered for sale(Section CITY TEL. NO.
7044, Business and Professions Code).
OWNER
❑ I, as owner of the property, am exclusively contracting ' P°
with licensed contractors to construct the project (Sec- MAIL
tion 7044, Business and Professions Code). ADDRESS t7l
CONSTRUCTION LENDING AGENCY CITY TEL. NO.
I hereby affirm that there is a construction lending agency for TPM
the performance of the work for which this permit is issued CONTRACTOR C%° ft
(Sec. 3097, Civ. C.).
ADDRESS c
Lender's Name
CITY
Lender's Address
STATE LIC.
I certify that I have read this application and state that the LICENSE NO. CI C% CLASS G !aC9
above information is correct. I agree to comply with all County
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter
upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
aziA)A-7
S(ghature of Applicant or Agent 0 Date