HomeMy Public PortalAbout4914 PERSIMMON AVE_Mechanical__ WertiWORKERS'COMPENSATION DECLARATION w " I L t lJkPPLICATION
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affirm that Lha-e a certificate of consent to self FOR PERMIT
q.a.certihcate of Workers'Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
fied copy thereof(Sec. 3800, Lab. C.) 76A364C I
JJ` /(:w CE-818(REV. 10/81)
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❑' Certified capy'is'hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING -77ADDRESS f P/
tion cippartmeot. (PRINT OR TYPE ONLY)
Date 1;5-1:30—Applicant I 11`71zz MF 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 involve/by ABSORPTION UNIT, BTU DISTRICT NO PROCESSED BY
the permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
I certify that in the performance of the work for which this G
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers'CoF
nsation WS. BOILER, BTU APPROVALS DATE INS OR'S SIGNATURE
Date 0' pplicont '� U COMPRESSOR, BTU ROUGH
NOTICE TO APPLICANT: If, after making this Certificate qf VENTILATION SYSTEM FINAL
Exemption, you should become subject to theWorke s'
Compensation provisions of the Labor Code, you must f h- EVAPORATIVE COOLER VALIDATI
with comply with such provisions or this permit sh be
deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9f HEATER: SUSPENDED UNIT 6 I�
(commencing with Section 7000) of Division 3 of the Business WALL
and Professions Code,and my license is in full force and effect. 0.
0.
License NumberLic. Class
_ V
Contractor GC�'G �� Date
❑ I am exempt under Sec. V
Plan check fee0 3 7.9 A IL
B.&P.C. for this reason PERMIT ISSUING FEE$ �Q
Date: � # 0 0 0 0 0 8
Signature TOTAL FEE
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT o - 20.50
I hereby affirm that I am exempt from the Contractor's License o 0 0 '�Q Jr O c=t
Law for the following reason (Section 7031.5, Business and NAME
Professions Code): 0 8, 08-88
El1, 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 Code).
OWNER •Al
I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec- MAIL
tion 7044, Business and Professions Code). ADDRESS 4191,W �!�iJ'!'t✓�+Jc7
CONSTRUCTION LENDING AGENCY CITY-1 ' - TEL.
1 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& 7
Lender's Name �/
!/
Lender's Address CITY�J[T�/l .r� J TE. ..53 61-66 76
STATELIC. �7
I certify that I have read this application and state that the LICENSE NO. ��� -� jj/ CLASS C��✓�
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
.2n the above-mens'pried property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
ul"" 6- 9 -99
Signature of Applicant or Agent Dote