HomeMy Public PortalAbout6033 PRIMROSE AVE_Mechanical__ • WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
I hereby affirm tHat I'have a certificate of consent to self
insure;'or a certificate o'F Workers.'Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof(Sec. 3800, Lab. C.) 76A364C
CE-818(REV. 10/81)
Policy No.000477 pany rffT /RLAG-MA//ry
Certifiir ed 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 BUILDING 2
tion department.- (PRINT OR TYPE ONLY) ADDRESS J
Date Applicant LOCALITY �r
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. PROCESSE B
the permit is for one hundred dollars($100)or less.) 1
AIR HANDLING'UNIT,CFM
I certify that in the performance of the work for which-this
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws. BOILER,BTU n APPROVALS DATE I P CTO S SIGNATURE
Date Applicant COMPRESSOR,BTU v ROUGH
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATI
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU GR LTiY )
LICENSED CONTRACTORS DECLARATION FLOOR BTU U (J
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
'(commencing with Section 7000) of Division 3 of the Business - WALL
and Professions Code,and my license is in full force and effect.
o�-s 6's (7 971 C o A O
License Number Lic. Class ► # 0.o' 0 0 0 8 fJ
Contractor Date ,I o.- 4275 u
❑ I am exempt a Sec. w�
Plan check fee ° - 42750'
aB.BP.C. for this reason' to
Date: PERMIT ISSUING FEE$ 0528-87. Z
Signature 'TOTAL FEE
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
the structure is not intended or offered for sale(Section CITY TEL. NO.
7044, Business and Professions Code).
OWNER RA c
El 1, as owner of the property,am exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRESS �• ,1/ ��j�f�y
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 CONTRACTORk_6/I0,nU�lIIFt 6 T�C
(Sec. 3097, Civ. C.). _
ADDRESS 1S�/,� 4ft V S
Lender's Name
CIN AM 6 1 -L TEL. NO.�� -572- ,33..
Lender's Address S— IsTATE LIC. /(
I certify that I have read this application and state that the LICENSE NO. s�SS CLASS -Z4
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 b e-mentioned property for inspection purpoeses. SEE REVERSE FOR EXPLANATORY LANGUAGE
Chi!/ C.Z!. rC--2/ - 7
Signet of Ap cant or Agent Date