HomeMy Public PortalAbout5445 PARMERTON AVE_Mechanical__ WORKERS COMPENSATION DECLARATION ,
I hereby affKm that I have a certificate of consent to self APPLICATION FOR PERMIT
\ tvurre yr a certificate of Workers Compensation InsuranceHEATING-- VENTILATING - AIR CONDITIONING
•/or a cerhfred-copy thereof'(Sec 3800 Lab C J 76A3b1C .. s _ 1
/ tr CE 818(REV 10/81) . - -
�cy'No Company ,
Certified copy is hereby furnished r' COUNTY OF LOS ANGELES BUILDING AND SAFETY
WI
—Certified copy is filed with the county building inspec FOR APPLICANT TO FILL IN BUILDING PAR mcg () e
1 department 1��7T (�,/s// �r (PRINT OR TYPE ONLY) ADDRESS /
Date Applicant r'-'17� n� EOCAUTY 7�/yJ/yam
NO TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS ` NEAREST
COMPENSATION INSURANCE CROSS ST
(This section nand not ba completed if the work involved by ABSORPTION UNIT BTU DIst:Rla No P o t
the permit Is for one hundred dollars ($100) or lass) Q
AIR HANDLING UNIT CFM a Cl
I certify that in the performance of the work for which this F
permit is issued I shall not employ any person in any manner '
so as to become subject
sunApplicant bject to the Workers Compensation Laws BOILER BTU '1 _ AKROVALS DATE INS"5 SIG ATURE ,
Dote - Z C/ lG + COMPRESSOR BTU�� (/ 1` ROUGH
NOTICE TO APPLICANT If after making this Certificate of VENTILATION SYSTEM FINAL
Exemption you should become subject to the Workers s — t ftt;5k I
' Compensation provisions of the Labor Code you must forth + +, EVAPORATIVE COOLER VALID
with comply with such provisions or this permit shall be 5!"�T/ ,
deemed revoked FURNACE FAU �(V 1 4-I-C,/VITY c /
LICENSED CONTRACTORS DECLARATION FLOOR TU Y _ :9 5 4 9 5 A
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER SUSPENDED" UNIT— - # 8
e
(commencing with h Section 7000) of Division 3 of the Business y
and Professions Code and my license is in full force/and effect _ - Iia • 4 4 5 0 0
License Number—�• Z� Lic Class ^" / " ' -- ► • e a 4 4 5 0 6
st�t/JoQG7/iORiQf[Datru 0924--86 O
Contractors e t-
❑ I am exempt under Sec _ f/—��� u
r Plan check fee , W
d
B BP C for this reason �Gjjr � .
„ - PERMIT ISSUING FEES , L) z Z
' Date
TOTAL FEE
Signature
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
-Professions Code) '
❑ I as owner of the property, or my employees with ADDRESS
wages as their sole compensation will do the work and CITY TEL NO ,
the structure is not intended or offered for sale(Section
7044 Business and Professions CodOWNER
a) - - 25494 A
_
❑ I as owner of the property am exclusively contracting MAIL _ ` a a e,e 8
with licensed contractors to construct the project (Sec ADDRESS
tion 7044 Business and Professions Code) a 5 0
CONSTRUCTION LENDING AGENCY CITY TEL NO` " ' f,
I hereby offnm that there is a construction lending agency for 4 5 05
the performance of the work for which this permit is issued CONTRACTOR •
(Sec 3097 Civ C ) - -0 9 2 4 . 6
' ADDRESS Y OlF^
Lender s Name �A
CITY /¢u/s�- C4 q/70Z TEL NO WI-
Lender s Address - TATEy ,
` I certify that I have read this application and state that the LSICENSE NO 7 CLASS
+ above information is correct I agree to comply with all County ,
ordm�es and $tate lows relating State laws relating to budding constructionand -ye y authorize representatouthorize representatives of this County to enter
u the above ntiop ned prope�Y for I�sPZ i,o p 'Poses SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent ,� '� Date