HomeMy Public PortalAbout6105 SAINT JAMES DR_Mechanical_8/8/1988_ A RKERS COMPENSATION DECLARATION
li hereby a rim
that I have a certificate of consent to self APPLICATION FOR PERMIT
inTure, or p<ertifico,e of Worker Compensation Insurance �IC HEATING - VENTILATING - AIR CONDITIONING
fled copy thereof (Sec 3800 La76A36
b C )
q /' ' ,/( AMY CE 810(REV 10/81)
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P❑ollcy NoCompany 2
Certified copy is hereby furnished COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with the county building ui%P ' FOR APPLICANT TO FILL IN BUILDING "'16
6 r.,[ /y� /�
Iiyii�+ri department (PRINT OR TYPE ONLY) ADDRESS ��V� Y /r/L�,J
Date gpphcant LOCALITY �p
NO TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS NEAREST t /
COMPENSATION INSURANCE CROSS ST /L/
(Thls iectlon need not be completed If the work Involved by ABSORPTION UNIT BTU DiSTRiCi No �/!y - PROCESSED BY
the peri Is for one hundred dollars($100)or less ) AIR HANDLING UNIT CFM �L I/ Q
I certify that in the performance of the work for which this _
permit is issued, I shall not employ any person in any manner BOILER BTU
so as to become subject to the Workers Compensatmn Laws _ APPROVALS DATE IN R S sia TUBE
Dote1 1, Applicant I COMPRESSOR BTU I• .600 ROUGH
NOTICE TO APPLICANT If after making this Certificate of VENTILATION SYSTEM FINAL
Exemption you should become' subject to the'Workers
Compensation provisions of the Labor Code you must forth EVAPORATIVE COOLER VALIDAji ON
with comply with such provisions or this permit shall be
deemed revoked FURNACE FAU_GR 1 n
LICENSED CONTRACTORS DECLARATION I FLOOR
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER SUSPENDED UNIT_
(commencing with Section 7000) of Division 3 of the Business WALL
and Professions Code and my license is in full force and effect d
sc20 e N La— O
License Number/0373 S L1c Class - - U
/� _W 9 7`"o i477i c cl
f OA/�2 �4//LA:2 Dare
Contractor Z 2 , _ , C
I am exempt under Sec su
Plan check fee d
B 8P C for this reason NPERMIT ISSUING FEE$ Z
Date
Signature TOTAL FEE
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT A 0 3 7 7 A
I hereby affirm that I am exempt from the Contractor s License , # e • • • • 8
Law for the following reason (Section 7031 5 Business and NAME
Professions Code) - I e - 3Q50
El I as owner of the property or my employees with
ADDRESS
wages as their sole compensation,will do the work andCITY TEL nq • ' e 3 Q 5 0 is
the structure is not intended or offered for sale(Section
7044 Business and Professions Code) OWNER 0a08_88
2 ,I- S ��
❑ I as owner of the property am axclusrvely contracting
with licensed contractors to construct the project (Sec MAIL /O T �S
tion 7044 Business and Professions Code) ADDRESS
CONSTRUCTION LENDING AGENCY Cm' /,e (;I, 7( TEL No 2Z7---4e7
I hereby affirm that there is a construction lending agency for ,
the performance of the work for which this permit is issued CONTRACTOR r V A /� 11A/
qp
(Sec 3097, Civ C ) - - -
ADDRESS yq E,,,,
Lenders Name
CITY TEL NO ?4C-31
Lender s Address
STATE LIC
I certify that I have read this application and state that the LICENSE NO q6 CLASS & 0 039
above information is correct I agree to comply with all County ,
ordinances and State laws relating to building construction
and hereby authorize rep'n" fives of this County to enter
up thea ve-mention pro rty for n,pec
on put eras SEE REVERSE FOR EXPLANATORY LANGUAGE
Y-9- p
' Signature of Applicant or Agent Dote