HomeMy Public PortalAbout6035 PRIMROSE AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION ) U-'
hereby"affirm that I have a certificate of consent to self APPLICATION FOR PERMIT
insure, or a certificale'of Workers'Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof(Sec:-3800, Lab. C.) 76M64C
CE-818(REV. 10/81)
P H y No.09? . J_A mpany FOt'i�lt71Jj /�il� [N/Z�
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 BUILDINGt®a
tion department. (PRINT OR TYPE ONLY) ADDRESS 604 (q/r
Date S-27^ 4tApplicant LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM ERS' NEAREST
COMPENSATION INSURANCECROSS 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.) AIR HANDLING UNIT,CFM
I certify that in the performance of the work for which this ) �Jt
permit is issued, I.sholl not employ any person in any mariner BOILER,BTU
so'as to become subject to'the Workers'Compensation Laws. APPROVALS DATE INSP 'S SIGNATUR
Date Applicant ( COMPRESSOR,BTU �60� 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 'If "i N
with'comply with such provisions or this permit shall be
deemed revoked. / FURNACE: FAU GRAVITY /O `l
LICENSED CONTRACTORS DECLARATION ( FLOOR BTU ! Dd
I hereby affirm that I am licensed under provisions of Chapter 9SUSPENDED + UNIT
'(commencing with Section 7000)of Division 3 of the Business HEATER: WALL
and Professions Code,and my license is in full force and effect. �
License Number a Lic.Class
>
Contractor Date 2-2-1 6 Un-
Plan
❑ I am exempt u r.Sec. W
Plan check fee ;271 2 8 A 0.
B.&P.C. for this reason' PERMIT ISSUING FEEZ
Date:
Q # 0 0 0 0 0 8
• Signature TOTAL FEE � •�,a o 4 2 7 5
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT .7S
I hereby affirm that I am exempt from the Contractor's License ► a 42.755
Law for the following reason (Section 7031.5, Business and NAME
Professions Code): o528-87
❑ 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). L G
OWNER ! trkdk Tsore
El1, as owner of the property,am exclusively contracting _
with licensed contractors to construct the project (Sec- MAIL y
tion 7044, Business and Professions Code). ADDRESS /� E �� (� dt,OB
CONSTRUCTION LENDING AGENCY CITYf L' TEL. NO.
I 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
Lender's Name ,�tt .N/
CITY S�T TEL. NO.WOP
Lender's Address ,
I certify that I have read this.application and state that the LI LICENSE NO. SATE 'Dss b/f CLASS. CO2.Z)
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 abo m rntioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of A>kantgent Date'