HomeMy Public PortalAbout6133 RENO AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION (LAPPLICATION FOR PERMIT CL
I hereby affirm that I have a certificate of consent to self
insure, oGatcertif!cote of Workers'Compensation Insurance, 'HEATING - VENTILATING - AIR CONDITIONING
or cycertified copy thereof(§ec. 3800, Lab. C.) 76A364C
t✓ r r�� r1 r CE-818(REV. 10/81)
Policy Not `7 C aany cGJ7Ft I �U IWJ
Certified copy is hereby furnished. COUNTY OF LOS ANGELES I BUILDING AND SAFETY
Certified copy is filed with the county building inspec- I FOR APPLICANT TO FILL IN BUILDING
tion d part ent. (PRINT OR TYPE ONLY) ADDRESS
Date Applicant ' LOCALITY r
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFI TE OF EXEMPTION ROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS 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.) I I III
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 APPROVALS DATE PEC R'S S NATU
� r
COMPRESSOR,BTU j ROUGH
Date Applicant
I NOTICE TO APPLICANT: If, after making this Certificate of I 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:. F GRAVITY
LICENSED-CONTRACTORS DECLARATION FLOOR DO BTU
ZAJ
' I hereby affirm that r 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.-70120-
�0 Z 2
License Number Lic.Class 11—e J , A. C
99
Contract Date to
❑ I am exempt under e . I LULU
Plan check fee
rq
BAP.C. for this reason' PERMIT ISSUING FEE ,Q S
D te:
Signature. TOTAL FEE
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Cant rc� or'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 CITY TEL. NO.
the structure is not'intended or offered for sale(Section
7044, Business and.Professions Code). OWNER
❑ I, as owner of the property, am exclusively contracting MAIL -2 0 9 4,5 A
with licensed contractors to construct the project (Sec-
tion 7044, Business and Professions Code). ADDRESS # o o 0 0 a 8
CONSTRUCTION LENDING AGENCY CITY TEL. NO 7
I hereby affirm that there is a.construction lending agency for II a - 5275
the performance of the work for which this permit is issued CONTRACTORt G ,
(Sec. 3097, Civ. C.). 'a a - 5 27 55
ADDRESS C I al 9-88
Lender's Name
CITY TEL.N2. w�JT _J5/
Lender's Address
STATE LIC.
I certify that I have read this application and state that the LICENSE NO. CLASS 02
I above information is correct. I agree to comply with all County i
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter ;
upon the above-mentioned property for inspection purposes. I SEE REVERSE FOR EXPLANATORY LANGUAGE
.Signature of Applicant or Agent Date