HomeMy Public PortalAbout6158 MUSCATEL AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION I APPLICATION FOR PERMIT
I hereby affirm that I have a certificate of consent to self I
insure„or a certificate of Workers'Compensation Insurance, 76A3d4C HEATING - VENTILATING - AIR CONDITIONING
ora certified copy thereof(Sec. 3800, La . C.)IJJ,��7 r CE-818(REV. 10/81)
Policy N0- Zl- d-t Company °
Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with the cou Id' g inspec- FOR APPLICANT TO FILL IN BUILDING
tion�Jdepartment. (PRINT OR TYPE ONLY) ADDRESS Gv�
Date r2 �� Applicant f�L�- LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEM ON 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($100)or less.) AIR HANDLING UNIT,CFM
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws. BOILER, BTU d APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant ® COMPRESSOR,BTU ROUGH 2�Z
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9. HEATER: SUSPENDED UNIT
'(commencing with Section 7000)of Division 3 of the Business WALL
and Professions Code,and my license is in full force and effect. A.
>_
�^ ��9 C. StS.
License Number) 6'-�/ 7� Lic. ClassO - �r> ► V
///�� L` d Cd
Contractor 4/D,1 62se� Date V
❑ I am exempt under Sec. LU
Plan check fee _ IL
{ B.&P.C. for this reason PERMIT ISSUING FEE$ ' 7 ' z
V
Signature te. TOTAL FEE a' �'CCT.4a'
OWNER-BUIL DECLARATION PLAN CHECK APPLICANT 3307 109.1919
I hereby affirm that I am exempt from the Contractor's License ,) 1 IT
EMI
Law for the following reason (Section 7031.5, Business and NAME / °
Professions Code): / TOTAL 109 -.5
m
El 1,
Off I, as owner of the property, or my employees with � HtC. 109at
�
wages as their sole compensation,will do the work and °
the structure is not intended or offered for sale(Section CITY ��� TEL. NO�� —7/ CHANGE .00
7044, Business and Professions Code).
OWNER ,of e ��
❑ I, as owner of the property, am exclusively contracting
11
with licensed contractors to construct the project (Sec- MAIL / C
tion 7044, Business and Professions Code). ADDRESS 0009-0001 1/ 1/93
CONSTRUCTION LENDING AGENCY CITY o C° TEL. NOZ 7952 1 PM12:24
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
Lender's Name
CITY TEL. NO.
Lender's Address
STATE ''7 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�V ?e
epresentatives of this County to enter
upon t ned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
lei 7
Signature of pp icant or Agent Date