HomeMy Public PortalAbout6133 MUSCATEL AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
y affirm that I have a certificate of consent to self
in I ,35r a certificate of Workers'Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
or a cel ,tfied copy thereof(Sec. 3800, Lob. C.) 76A364C
CE-818(REV. 10/81)
P11 olicy N Company Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
FQ Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING bl3 j �� � � ,
tion department. (PRINT OR TYPE ONLY) ADDRESS
Date Applicant LOCALITY G� 4 1�
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE J/l�T�'`���J ���
CERTIFICATE OF EXEMPTIO FROM WORKERS' NEAREST J�
COMPENSATION INSURANCE l`�` CROSS ST. La `7
(This section need not be completed If the work Involved by ABSORPTION UNIT, BTU O v DISTRICT NO. -J PROCESSED BY
the permit is for one hundred dollars($100)or less.) T(�
AIR HANDLING UNIT,CFM
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner BOILER,BTU
so as to become subject to the Workers'Compensation Laws. APPROVALS DATE INSPBeOR'S SIGNATURE
Date Applicant
COMPRESSOR, BTU i /O Vv ROUGH
O
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL �� mr�ay
IF
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth-. EVAPORATIVE COOLER VALIDATION
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU -
I hereby affirm that I am licensed under provisions of Chapter 9HEATER: SUSPENDED-UNIT-
'(commencing
USPENDED UNIT•(commencing with Section 7000)of Division 3 of the Business WALL
and Professions Code,and my license is in full force and effec
QL � o %;
License Number c+v � Lic. Class- 0� , t®i
@ l,� ne
Contractor pg-�C�6&--a&ateC- - Q O
❑ I am exempt under Sec. W
Plan check fee IL
8.8P.C. for this reason us
PERMIT ISSUING FEE$
Date:
Signature , A �' TOTAL FEE
I"
NER-BUILDER D CLARATION 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):
ElI, as owner of the property, or my employees with ADDRESS a
wages as their sole compensation,will do the work and ACCT A
CITY TEL. NO.
the structure is not intended or offered for sale(Section ,9 3307 11050
7044, Business and Professions Code). t�
OWNER
ElI
1TEMS I, as owner of the property,am exclusively contracting ;5 A i
with licensed contractors to construct the project (Sec- MAIL
ADDRESS TOTAL .IIt o�n�l
tion 7044, Business and Professions Code). i
CONSTRUCTION LENDING AGENCY CITY TEL. NO. CHECK 51.50
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued CONTRACTOR ' C E .00
(Sec. 3097, Civ. C.).
ADDRESS
Lender's Name Q II�-QQD1 6/12/89
CITY TEL. NO.
Lender's Address 3901 1 Aft 90-31
STATE LIC.
1 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
uoon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
S gnature of Applicant or Agent Date