HomeMy Public PortalAbout5337 PAL MAL AVE_Mechanical__ WORKERS COMPENSATION DECLARATION - - - APPLICATION FOR PERMIT
I hereby oHrcI have m that have a certificate of consent to self
Insure, or o certificate of Workers Compensation Insurance 7�364C HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof (Sec 3800 Lab C )
CE 818(REV I0�81)
PolPolicy No Company
Certified copy is herebyfurnishedCOUNTY OF LOS ANGELES
' BUILDING AND SAFETY
❑ Certified copy is filed with the county building mspec- FOR APPLICANT TO FILL IN BUILDING /
tion department (PRIM OR TYPE ONLY) ADDRESS C�
zil
Date Applicant LOCALI —
NO TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS NEARES �-
COMPENSATION INSURANCE CROSS ST
(This section need not M comple
ted if the work involved by ABSORPTION UNIT BTU PROCESSED BY
�
the permit is for one hundred dollars ($100)or loss ) f/
AIR HANDLING UNIT CFM DISt4iCT IJOY
I certify that In the performance of the work for which this
permit is issued I shall not employ any person In any manner BAILER BTU
so as to becomeisouid
ct toJnt
kers'Compensation s Aw4OVALS DATE INSPECTOR S SIGNATURE
r
COMPRESSOR BTU ROUGH
Dat1 —NOTICE TO APPLT Ifmaking this Certdicote of VENTILATION SYSTEMFINAL
xemption yousublect to the WorkersCompensation provisions bor Code you must forth EVAPORATIVE COOLER LIDAT N
with comply with such provisions or this permit shall be
deemed revoked FURNACE FAU V GRAVITY
LICENSED CONTRACTORS DECLARATION / FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER 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 effect Y
d
License Number Llc Class , cc
K
Contractor Date O
❑ I am exempt under Sec C
N
B 6P C for this reason Plan check fee CL
ISSUING FEE $
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 ���CS ' �/)v
Professions Code) I
A�❑ I as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and Cin, /x TEL i 3 — - 8684A
the structure is not intended or offered for sale(Section 1.
7044 Business and Professions Code) OWNER q)7$ a # • • • • 8
/ •
❑ I as owner of the property am exclusively contracting 2 • 4 2 0 5 0
with licensed contractors to construct the project (Sec MAIL
bon 7041, Business and Professions Cada) ADDRESS i
CONSTRUCTION LENDING AGENCY CITY TEL NO s ' P 2 O O v
I hereby affirm that there is a construction lending agency for , 1 230-82
the performance of the work for which this permit Is Issued CONTRACTORJll
(Sec 3097 Gv C )
ADDRESS
Lander s Name ez
CITYTEL No
Lender s Address
STAI certify that I have read this application and state that the LICENSE NO CLASS
above Information is correct I agree to comply W Ith all County
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter
u n the above mentioned r pefly for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
nature of AppLcon,or Agent Date