HomeMy Public PortalAbout5940 RENO AVE_Mechanical__ i
KERS'COMPENSATION DECLARATION APPLICATION . FOR PERMIT
that I have a certificate of consent to self ;
Iqlaffirrit
r a certificate of Workers'Compensation Insurane, HEATING - VENTILATING - AIR CONDITIONING
ified copy thereof(Sec. 3800, Lab. C.) 7 k
76A364C
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PolIcy.No8= Company
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❑ 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 BUILDING
tion department. f I ADDRESS,5'? 0
_�1 /� (PRINT OR TYPE ONLY)
Date Applicant�In. .��Y. /' I i I LOCALITY J
NO. TYPE OF APPLIANCE OR EQUIPMENT. FEE NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE CROSS ST.
ri ti
(This section need not be completed if the work involved by ABSORPTION UNIT,BTU DISTRICT NO. PROCESSE Y�{
the permit is for one hundred dollars(;100)or less.) AIR HANDLING UNIT,CFM oK
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner = BOILER,BTU
'so as to become subject to the Workers'Compensation Laws. APPROVALS DATE iNyEcfiR,s SIGNATURE
Date Applicant COMPRESSOR,BTU ROUGH
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL j
Exemption, you should become subject to -the Workers'.;
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATIO •
with comply with .such provisions or this permit shall be I
deemed revoked. FURNACE: FAU GRAVITY
'LICENSED CONTRACTORS DECLARATION FLOOR - BTU
I hereby affirm that I am licensed under provisions of Chapter 9 I / HEATER: SAL NDED UNIT
'(commencing with Section 7000)of Division 3 of the.Business
and Professions Code,and my license is in full force and effect.
License Number 146—)76/ Lic. Class
r t�
Contractor V D ,I� Date 0
❑ I am exempt under Sec.
Plan check fee H
B.BP.C. for this reason-
Date: �+
PERMIT'ISSUING FEE S •
rV
Signature TOTAL FEE ,6
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License , w2 6 3 a 3 R
Law for the following reason (Section 7031.5, Business and! NAME
Professions Code): #
ADDRESS1
El I-, as owner of The property, or my employees with 1 ° o20,50
wages as their sole compensation,will do the work and NO.
the structure is not intended or offered for sale(Section, CITY TEL. o a o 2.0,5 Q 53
7044, Business and Professions.Code).
OWNER �'. �f Q 1,2 2 =s 7
❑ I, as owner of the property,am exclusively contracting '
with licensed contractors to construct the project (Sec-; 'L
tion 7044, Business and Professions Code). ADDRESS
CONSTRUCTION LENDING AGENCY ; CITYTEL. NO. 7
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.). tIZI
ADDRESS , S
Lender's Name
y CITY TEL. NO.
Lender's Address
STATE � CLASS
I certify that I have read this application and state that the LICENSE NO. c3 dea
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 i
upon the above-mentioned property for inspection purposes: SEE REVERSE FOR EXPLANATORY LANGUAGE
JAI
Signature of Applicant or Agent Date