HomeMy Public PortalAbout5753 ROWLAND AVE_Mechanical__ i. '� WgRKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
I hereby affN+tl that I have a certificate of consent to self
insure, or a certificate of Workers'Compensatiorq Insurance, 76A364� HEATING - VENTILATING - AIR•CONDITIONING
ora e+tr Fopy thereof(Sec. 3800, Lab.C.)
t3 _ V t, CE-818(REV. 10/81)
Policy 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 r
tion department. ADDRESS S 7� WCE(yLo ALC,
(PRINT OR TYPE ONLY)
Date Applicant LOCALITY 141.PI C
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE NEAREST f
COMPENSATION INSURANCE CROSS ST. ICJAA 4/j ✓C.
(This section need not be completed if the work Involved by ABSORPTION UNIT,BTU DISTRICT NO. PROCESSED
the permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws. BOILER,BTU APPROVALS DATE IN ECTOR'S SIGNATURE
j Dat@ l v Z pplicant •COMPRESSOR,BTU r ROUGH J v
NOTICE tO APPLICANT: If, after making. this 'Certificate of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDA N
with comply with such provisions or this permit shall be
deemed revoked. I FURNACE: FAUGRA TY
- LICENSED CONTRACTORS DECLARATION FLOOR BTU Q�U 0
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED-UNIT-
'(commencing
USPENDED UNIT'(commencing with Section 7000) of Division 3 of the Business WALL
and Professions Code,and my license is in full force and effect.
O
License Number Lic. Class U
Contractor Date
❑ I am exempt under Sec. ILU
Plan check fee IL
B.BP.C. for this reason' PERMIT ISSUING FEE$ 10 90
Date: F
Signature .
TOTAL FEE •I e o 3 Q 5 0
OWNER-BUILDER DECLARATION PI jN CHECK APPLICANT :a a a 3 Q 5 0 5
I hereby affirm that I am exempt from the Contractor's License I. ► I o.24-85
Law for the following reason (Section 7031.5, Business and NAM ,UAJProfessions Code):
' i, as owner of the property, or my employees with ADDRESS 3 W 7 &
wages as their sole compensation,will do the work and • CITY / TEL. NO.
the structure is not intended or offered for sale(Section GC" 1 L �ZZ
7044, Business and Professions Code).
OWNER
❑ I, as owner of the property,am exclusively contracting
with licensed contractors to construct the project (Sec- MAIL
tion 7044, Business and Professions Code). ADDRESS
CONSTRUCTION LENDING AGENCY CITY TEL. NO.
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.).
ADDRESS
Lender's Name
CITY TEL. NO.
Lender's Address
STATE LIC.
I certify that I have read this application and state that the LICENSE NO. CLASS
above informatidn is correct. I agree to comply with all County
ordinances and State laws relating to building construction,
and h reby authorize.representatives of this County to enter
u t e above- ned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
2,4
Signature of Applicant or Agent Date