HomeMy Public PortalAbout6206 RENO AVE_Mechanical__ WORKEOS'CdMkITNSATION DECLARATION
I hereby'affirm that I .have a certificate of consent to self APPLICATION. FOR PERMIT
insure,%oga ce%ficate of Workers'Compensation Insurance, HEATING - VENTILATING �- AIR CONDITIONING
or a certified copy thereof(Sec. 3800, Lab. C.') 76A364C
ICE-818(REV.. 10/81)
Policy No1L2Company /f�Certified copy is hereby furnished. COUNTY OF LOS ANGELES I BUILDING AND SAFETY \
Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING ADDRESS Av �� ewd
tiio/n�de/paa tm/nt. r r— (PRINT OR TYPE ONLY) AOCALI7Y
Date /c/�r/ ✓<P Applicant A1.- /!� I e'e w ,
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE,OF EXEMPTION FROM WORKERS' NEAREST r
COMPENSATION INSURANCE CROSS ST. A ole
(This section need not be completed if the work involved by ABSORPTION UNIT,BTU i DISTRICT NO. PR BY
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 I
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws. BOILER,BTU I APPROVALS DATE I SPE OR'S SIG004VE
h i
Date Applicarit COMPRESSOR,BTU. 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 VALIDA
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU G VITY /
LICENSED CONTRACTORS DECLARATION FLOOR BTU . /Q
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED 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.
� /n�A,��/ 1 S'?' 0
NG0
License Number Lic. Class OA
. 60i
Contractor ax� J� Date D' �`
❑ I am exempt under Sec. M
Plan check fee IL
IL
B.&P.C. for this reason PERMIT ISSUING FEE$
Date:
TOTAL FEE
Signature '
OWNER-BUILDER DECLARATION PAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License ,
Law for the following reason (Section 7031.5, Business and NAME
Professions Code):
❑ • I, as.,
s 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).
OWNER
-❑ I, as owner of the property,am exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRESS26 6 , �T
1 tion 7044, Business and Professions Code). ��'Jr b 2 2 A
CONSTRUCTION LENDING AGENCY CITY TEL. NO.
I hereby affirm that there is a construction lending agency for c _ '# 0 0 0.0 0 8
the performance of the work for which this permit is issued CONTRACTOR
(Sec. 3097, Civ. C.). . ,• '( o o 5 5,0 0
ADDRESS //
Lender's Name av 0 0 0 5 5 0 05
CITY/r
TEL. NO
Lender's Address /� 4STATE a 13�-8 6
1 certify that I have read-this,application and state that the% LICENSE NO.e5 2eV CLASS e-
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
��th above- ti n d rty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
9Signoture of Applicant or Agent Date