HomeMy Public PortalAbout6024 RENO AVE_Mechanical__ WORKERS' .i.,ha COMPENSATION' f APPLICATION F®R PERMIT
.�insurgbOraafcertif ceirm rtificate of Wo kers"Compensation if!cafe of insuranceent to , EN
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or a certified copy thereof(Sec. 3800, Lab.wC.), , r 76A364C I�EA��i�G - VENTILATING - ADR C®NI®��I®NBfVG
CE-818(REV. 10/81)
Poly No. Company
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 _
PQ
tion department. (PRINT OR TYPE ONLY) ADDRESS
Date Applicant 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 involved by ABSORPTION UNIT, BTU DISTRICT NO. PROCESSED )
the permit is for one hundred dollars($100)or less.)
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM
permit is issued, I shall not employ any person in any manner BOILER,BTU
so as to become subject to the arkers'C pensatio La s. APPROVALS DATE INSP R'S ATu E
Date �� �� pelican COMPRESSOR,BTU ROUGH
NOTICE O APPLICANT: If, afte making this Certificate of VENTILATION SYSTEM FINAL o-
Exemption, you should becom subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU
LICENSED CONTRACTORS DECLARATION FLOOR BTU l!
I hereby affirm that I am licensed under provisions of Chapter 9HEATER: WALL SUSPENDED UNIT
''(commencing with Section 7000) of Division 3 of the Business — �
and Professions Code,and my license is in full force and effect. 1_6 ' ¢ �� ®�e S
O
License Number Lic. Class Poo. V
09
Contractor Date
❑ I am exempt under Sec.
Plan check fee
rA
BAP.C. for this reason PERMIT ISSUING FEE$ Z
Date:
Signature TOTAL FEE 289211 R
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT R + 0 0 0 °40
I hereby affirm that I am exempt from the Contractor's license
Law for the following reason (Section 7031.5, Business and NAME ', 'l .. . 48.0 0
Professions Code):
I, as owner of the property, or my employees with ADDRESS •° ° ° 4 a 0 0=�
wages as their sole compensation,will do the work and
the structure is not intended or offered for sale(Section CITY TEL. NO. -0207-8 8
7044, Business and Professions Code).
OWNEOA R
❑ I, as owner of the property,am exclusively contracting MAIL '1 ' c
with licensed contractors to construct the project (Sec- ADDRESS Qpl�
tion 7044, Business and Professions Code). ��.
CONSTRUCTION LENDING AGENCY CITY l r TEL. NO.
I hereby affirm that there is a construction lending agency for v"
the performance of the war for which this permit is issued CONTRACTOR
(Sec. 3097, Civ. C.).
• ADDRESS
Lender's Name
CITY ( L. NO.
Lender's Address' '
I certifythat I have read this application and state that the STATE / LIC.
pp LICENSE NO. CLASS
above information is correct. I agree to comply with all County
ordinances and State laws relating to building construction,
and hereby authori re esentatives of this County to enter
upon the ab e- e io property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGLPAGE
' �,U IQ i
ignature of Applicant or Agent /Date