HomeMy Public PortalAbout6202 RENO AVE_Mechanical__ L. WORKERS'COMPENSATION DECLARATION
116re6y affirm that I have'ill certificate of consent,•to self APPLICATION FOR PERMIT
insure, or a certificat�kf Workers'Compensation Insurance
or a ceRtified coppy thereof f,�ec. 3800, La . .) Z6A364C HEATING - VENTILATING - AIR CONDITIONING
Policy No. DPk_
:Eoany
X46 DPW 9/88
y
Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
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❑ Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING V -,
tU-7T
nt. (PRINT OR TYPE ONLY) ADDRESS (:2_10
DateApplicant ff� — LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEARESST. 66/1/x-QfJ/(r
COMPENSATION INSURANCECROSS
(This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO. I PROCESSED BY
the permit is for one hundred dollars(;100)or less.) I ,p
I certify that in the performance of the work for which this AIR HANDLING UNIT, CFM n� y
permit is issued, I shall not employ any person in any manner �i GSL
so as to become subject to the Workers'Compensation Laws. BOILER, BTU APPROVALSDATE INSPECTOR'S SIGNATURE
Date Applicant COMPRESSOR, BTU a ROUGH
NOTICE TO APPLICANT: If, after making this Certificate of. VENTILATION SYSTEM FINAL y
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 deem-
ed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION 4— FLOOR. BTU Ti
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED—UNIT
(commencing
USPENDED UNIT(commencing with Section 7000)of Division 3 of the Business WALL.
and Professions Code,and my license is in f u I I force and effect.
�fI - — O
License Number Lic. Class
Contractor Date
❑ I am exempt under Sec. O
Plan check fee Lu
U
B.&P.C. for this reason Z
PERMIT ISSUING FEE $ �% C7
Date: .. TOTAL FEE J'/ d O
'
Signature
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT -Fe _ • ell), . L
I hereby affirm that I am exempt from the Contractor's License } "
Law for the following reason (Section 7031.5;Business and NAME Ln Q p1 4\ alASt, , ACCTA
Professions Code): `� 'g '
❑ I, as owner of the property, or my employees with ADDRESS d.Z d s"�'qt Elf
wages as their sole compensation,will do the work andCITY O. 1 iTt31S
the structure is not intended or offered for sale(Section .(�j1 Dr�.l { d 0 i S o
7044, Business and Professions Code). OWNER j��AA -. TOTAL I AL 51 �00
❑ I, as owner of the property, am exclusively contracting rr'rs
MAIL
with licensed contractors to construct the project (Sec- ADDRESS �Cj 2 11 CHECK
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY _FQA4A .Q C-, TEL. NO. z 7.6 HANGS .00
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.). j 7/90
((��� �� �S
Lender's Name ADDRESS 769 1 AM 11 d 01
CITY �N Q C 1 TEL. NO. — �
Lender's Address
I certifythat I have read this application and state that the STATE LIC.
PP LICENSE NO. d CLASS
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 above-mentioned property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Age9t Date