HomeMy Public PortalAbout6003 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, 76A364C HEATING - VENTILATING - AIR CONDITIONING
or a certifie copy thereof(Sec. 3800—Lab:P_ CE-818(REV. 10/81)
Policy N UZZ? 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 � '�
n d
eepartrnea}. (PRINT OR TYPE ONLY) ADDRESS G 'e
DatApplicant (a�iL2fl�% LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST. _
(This section need not be completed if the work Involved by ABSORPTION UNIT, BTU DISTRICT NO PR SSED B
the permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM ^
1 certify that in the performance of the work for which this .
permit is issued, I shall not employ any person in any manner BOILER, BTU
so to become subject to the Workers Compensation Laws. APPROVALS DATE IN ECTOR'S SIGNATURE
COMPRESSOR, BTU ROUGH
Date Applicant
NO E TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL ` r
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATI N
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED—UNIT—
(commencing
USPENDED UNIT(commencing with Section 7000) of Division 3 of the Business WALL
and Professions Code,and my license is in full force and effect. / IL
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2License Number /J_o' 5 Lic. Class111110
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Contracto IM6a7`ulatel, 0.5 7 qJ
❑ I am exempt under Sec. W
Plan check fee a
in
B.BP.C. for this reason 6)
PERMIT ISSUING FEE$
Dote: TOTAL FEE
Signature
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT ;22330A
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and NAME # ° o a ° ° 8
Professions Code):
❑ I, as owner of the property, or my employees with ADDRESS ° - 3050
wages as their sole compensation,will do the work and CITY TEL. NO.
thestructure is not intended or offered for sale(Section ° ° ° 3 Q 5 0�'
7044, Business and Professions Code). OWNER 0 626-85
❑ I, as owner of the property, am exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code).
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 7K i7rav
Lender's Name
Lender's Address CITY G'-7i67-,rV TEL. NOa 4,?
a��`
STATE f�/•�
I certify that I have read this application and state that the LICENSE NO. J..S CLASS
above information is correct. I agree to comply with all County
ordinances and State laws relating to building construction,
and he by au representatives of this County to enter
o e ab a-me boned propert for inspection Vurposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
e,//_ .
Signature of Applicant or Agent Date