HomeMy Public PortalAbout5812 MUSCATEL AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
I hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers' Compensation Insurance,
or a ce lfiedcoy the oC9f (SAc. 3800, Lab. C,) '76A364C BEATING - !VENTILATING - AIR CONDITIONING
Palicy`�o: " Company , 20-0046 DPW 9/88
Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with the county buildin inspec- FOR APPLICANT TO FILL IN BUILDING
tionKApplirnnt.A
ADDRESS
(PRINT OR TYPE ONLY)
DateNO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY
CECOMPEN ATI INSURAN EATE OF EXE 4N FROM ORKERS' CROSSNEARESST. I f
(This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO. / PROCESSED Y
the permit is for one hundred dollars ($100)or less.)
I certify that in the performance of the work for which this AIR HANDLING UNIT, CFMtA
permit is issued, I shall not employ any person in any manner BOILER, BTU l/
so as to become subject to the Workers'Compensation Laws. APPROVALSTE I PE S SIG
Date pplicantNATURE
ACOMPRESSOR, BTU 3�od j�o ROUGH
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL A r14 XX
Exemption, you should become subject to the Workers' /
Compensation provisions of the Labor Code, you.must forth- EVAPORATIVE COOLER VALID T '
with comply with such provisions or this permit shall be deem-
ed revoked. FURNACE: FAU ( —
LICENSED CONTRACTORS DECLARATION FLOOR BTU IN
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 forcand effect. //
License Number Lic. Class ► O
U
Contract Date 09
❑ I exempt under Sec.
Plan check fee U
B. P.C. for this reason
Date: PERMIT ISSUING FEE $ W
Signature TOTAL FEE
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):
El 4
I, as owner of the property, or my employees with ADDRESS
r.
wages as their sole compensation,will do'the work and AC (°'c
the structure is not intended or offered for sale(Section CITY TEL. NO.
7044, Business and Professions Code). OWNER � 3307
t1'rill,
F-1 Ias owner of the property, am exclusively contracting I ITEMS
with licensed contractors to construct the project (Sec- MAIL �
tion 7044, Business and Professions Code). ADDRESS 2 ase Are G TOTAL 57 ® 00
CONSTRUCTION LENDING AGENCY CITY - TEL. NO./&� 30 '7 {� �� �517.01'
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued CONTRACTOR b C{{ j1I[7E ,Val
(Sec. 3097, Civ. C.).
ADDRESS 7 dr Alf l
Lender's Name �l 11111111011-00011111011-0001{-0001 7/31 LI
• CITY TEL. NO.
Lender's Address STAT v LIC. A 138 1 A r1l 8 {j^
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 he eby authori a representatives of this County to enter
up n e above- ntio ed property for inspectign purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
S' nature of Applicant or Agent Dote f