HomeMy Public PortalAbout6038 MUSCATEL AVE_Mechanical__ WORKERS"COMPENSATION DECLARATION IPV—' t 4 '/^AppLICATIOI� FOR PERMIT
I�hereby affirm 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 thereof (Sec. 3800, Lab. C.) 76A364C
/, CE-818(REV. 10/81)
Policy No. e Uis Company COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is hereby furnished.
❑ Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING
tion department. / (PRINT OR TYPE ONLY) ADDRESS - Q
Date — Z' Applica.nt rt- I UN Bah LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE NEAREST
CERTIFICATE OF EXEMPTION FROM WORKER '
COMPENSATION INSURANCE CROSS ST.
(This section need not be completed if the work Involved by ABSORPTION UNIT, BTU DISTRICT NO PROCESSED
the permit is for one hundred dollars($100)or less.)
AIR HANDLING UNIT,CFM
I certify that in the performance of the work for which this d0
permit is issued, I shall not employ any person in any manner BOILER, BTU
so as to become subject to the Workers'Compensation Laws. APPROVALSDATE INS.P OR'S SIGNAT E
Date Applicant COMPRESSOR, BTU ROUGH ci _
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL )
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATI N
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9HEATER: SUSPENDED UNIT
X
(commencing with Section 7000)of Division 3 of the Business WALL �
and Professions Code,and my license is in full force and effect.
License Number ��/Z���� Lic. Class ® to
i• d( ( f date
Contractor �+At rUi TC O
❑ I am exempt under Sec.
Plan check fee IL
H
8.8P.C. for this reason PERMIT ISSUING FEE$ U
Date:
Signature TOTAL FEE Q
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).
OWNER
❑ I, as owner of the property, am exclusively contracting MAIL c U 6 4.8 A
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code). 4 0 0 0 0 0 8
CONSTRUCTION LENDING AGENCY CITY TEL. NO.
I hereby affirm that there is a construction lending agency for ® i o o F
the performance of the work for which this permit is issued CONTRACTOR
(Sec. 3097, Civ. C.). 0912-88
ADDRESS
Lender's Name
CITY TEL. NO.
Lender's Address STATE LIC
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 hereby authorize representatives of this County to enter
upon the above- entioned pro erty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant o gent Date