HomeMy Public PortalAbout5232 PAL MAL AVE_Mechanical__ .4- „ m WORKERS'COMPENSATION DECLARATION
IJ&,reby ,pffirthat I have a certificate of consent to self APPLICATION FOR PERMIT
insure, or a certificate of Workers'Compensation Insurance, HEATING .- VENTILATING - AIR CONDITIONING
or a certified copy thereof(Sec. 3800, Lab. C:) CE-81 C
CE 818(REV. 10/81)
Policy No. Company Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING,AND SAFETY
❑ Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDINGr� ?��
tion department. (PRINT OR TYPE ONLY) ADDRESS r V
Date Applicant LOCALITY
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($100)or less.) A�
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM /vJ
permit is issued, I shall not employ any person in any manner 61
BOILER,BTU
so as to become subject to the Work 'COm atlon ws. APPROVALS DATE I OR'S SIGNATURE
7 A COMPRESSOR,BTU ROUGH
Date ppl lcgg
NOTICE TO APPLICANT: If, dt$er makirig thi 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 9 HEATER: SUSPENDE�UNIT �l
'(commencing with Section 7000)of Division 3 of the Business WALL (f
and Professions Code,and my license is in full force and effect.
O
License Number Lic. Class , t�
Contractor Date O
P_
❑ I am exempt under Sec. U
P 7 8 a 8 A
B.BP.C. for this reason' Plan check fee " � �
Date:
PERMIT ISSUING FEE$ U 8
Signature TOTAL FEE # .0 a a 0 0
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT ° o 2 Q 5 O
I hereby affirm that!am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and NAME , � , a 0 0 2 Q 5.0 5
Professions Code): ,
r-
1, as owner of The property, or my employees with 2 -3 Z / Q 9,•1 0-87
wages as their sole compensation, ADDRESS J will do the work and
the structure is not intended or offered for sale(Section CITY ;£ / d TEL. NOJf1k V41_
7044, Business and Professions Code).
OWNER Z
❑ I, as owner of the property, am exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code):
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 CONTRACTO ,
(Sec. 3097, Civ. C.).
ADDRESS
Lender's Name
CITY TEL.NO.
Lenders 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 author representatives of this County to enter
uPon above- eTt oned pro rty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of plicant or ent Dote