HomeMy Public PortalAbout6024 MUSCATEL AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION AWL l CA N O R ARWIT
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ereby affirm that I have a certificate of consent to self
I urs, or o certificate of Workers'Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
r certL414cgpy�Jl�e of(Sec. 3800, L b C. CE-81 C
`"'11 YYJJ``Zz((pp CE-818(REV. 10/81)
❑olicy No. Company
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d copy is hereby furnished. COUNTY OF LOS ANGELES CC BUILDING AND SAFETY
d copy is filed with co building inspec- FOR APPLICANT TO FILL IN BUILDING J.S�
oepartment. (PRINT OR TYPE ONLY) ADDRESS
r��� l LOCALI C
Date pp i n 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 PROCESSED BY
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,CFM
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 INSPECTOR'S SIGNATURE
Date Applicant COMPRESSOR, BTU ROUGH /0 Z 7- yS
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL �•�9� s �•c-�-�
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
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9HEATER: 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. l• v av� Z
I tS
License Number Lic. Class p , ki
( II—W
Contractor Date
❑ 1 am exempt under Sec. LU
Plan check fee y
B.BP.C. for this reason PERMIT ISSUING FEE $ 1 eja
Date:
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):
❑ I, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and
the structure is not intended or offered for sale(Section CITY TEL. NO.
7044, Business and Professions Code). 17__�
OWNER e
❑ I, 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 CI� TEL. NO.
41 J
1 hereby affirm that there is a construction lending agency for Ir
the performance of the work for which this permit is issued CONTRALTO
(Sec. 3097, Civ. C.).
ADDRESS - tJF
Lender's Name
CITYars if TEL. NO. �
C
Lender's Address
STATE LIC.
I certify that I h ve read this application and state that the LICENSE NO. o CLASS
above inform on is correct. I agree to comply with all County
ordinances d State laws relating to building construction,
---cR�l her by au(iorize representatives of this County to enter
o e-mentions property for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature'of Applicant or Agent Date