HomeMy Public PortalAbout6412 OAK AVE_Mechanical__ I del
W_r3KERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
I hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers'Compensationdnsurance, HEATING - VENTILATING - AIR CONDITIONING
or a cartifi€d op the pof Sec. 3800 L 76A364C
v 1 CMM G� , �7� �- CE-818(REV. 10/81)
rP_oTllcy d ompany„/"fi1/7c rC rd//�fi��
LJ Certified copy is hereby furpished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING
ADDRESS
tion d partm t. J (PRINT OR TYPE ONLY) /� L
Date Applican dltefu LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE NEAREST Z_
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($100)or less.) <r `�
AIR HANDLING UNIT,CFM /
I certify that in the performance of the work for which this .Jt,(�J
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws. BOILER, BTU APPROVALS DATE IN TOR'S SIGNATURE
Date Applicant COMPRESSOR,BTU 0 ROUGH ' J
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDA N
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAUZh_G
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
(commencing with Section 7000)of Division 3 of the Business WALL
and Professions Code,and my license is in full force and effect. �� - 0.
O
License NNumbee:2 7lf �10Lic. Class poll. IIXr
Contraco `Dte''
❑ I am exempt under Sec. W
Plan check fee IL
B.BP.C. for this reaso0 �
PERMIT ISSUING FEE$ `�1.5�
Date: TOTAL FEE (7 0 a,6 96.6 A
Signature
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT t o o a 0 0 8
1 hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and NAME
Professions Code):
El1, as owner of the property, or my employees with ADDRESS (0 0 0 8 ci)
wages as their sole compensation,will do the work and CITY TEL. NO.
the structure is not intended or offered for sale(Section 0 E05—8 7
7044, Business and Professions Code).
OWNER
❑ 1, 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 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 " fJ
(Sec. 3097, Civ. C.). /
ADDRESS r �•� � ()(, - ,�(
Lender's Name �,_
CITY i TEL. NO. �� &J-
Lender's Address l
STATEi�/ oLIC. , r�!
1 certify that I have read this application and state that the LICENSE NO. f 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-ment�ionnpd property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date