HomeMy Public PortalAbout6333 SALTER AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
I herebx affirm that I have a certificate of consent to self
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1ure, o0a certificate of Workers'Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof(Sec. 3800, Lab. C.) 76A364C
(ASC C_ A4' �{� / 818(REV. 10/81)
Policy No. CompanySc.12ee i0�� 'viv�y
Certified copy is herieby furnished. COUNTY OF'LOS ANGELES BUILDING AND SAFETY
❑ Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING ( "3 3 3
tion department. (PRINT OR TYPE ONLY) ADDRESS A' tom.
Date��`` f( LOCALITY
! —Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE e C e'-
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST. e I
(This section need not be completed if.the work involved by ABSORPTION UNIT, BTU DISTRICT NO. PROCESSED BY s
the permit is for one hundred dollars($100)or less.) ` rp f
I certify that in the performance.of the work for which thisAIR HANDLING UNIT,CFM' U
permit is issued, I shall not employ any person in any manner
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so as to become subject to the Workers'Compensation Laws, BOILER,BTU a APPROVALS DATE INSPE R'S SIGNATURE
Date Applicant COMPRESSOR,.BTU ROUGH r
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION
with comply with such provisions or this .permit shall be
deemed revoked. f FURNACE: FAU Ggg,gqVITY '1
LICENSED.CONTRACTORS DECLARATION / FLOOR BTU fo a CV% U Lid -
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
'(commencing with Section 7000) of Division 3 of the Business - WALL
and Professions Code,and.my license is.in full force and effect.
License Number 5 7-6 2 ro —Zv
l Lic. Class ,
` a/15/OGte � Cf- 9E
Contractor o 4 3
�c°vim'
❑ I am exempt under Sec. U
Plan check fee
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B.&P.C. for this reason'
Date:
PERMIT ISSUING FEE$ (�
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Signature TOTAL FEE
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT ;2'5,1 8 O A
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and NAME , 1 0 0 0 0 0 8
Professions Code):
❑ I, as owner of the property, or my employees with ADDRESS ;I ° ° 3 Q 5 0
wages as their sole compensation,will do,the work and
thestructure is not intended or offered for sale(Section CITY TEL. NO, ?.o o,0 3115 0 5
7044, Business and Professions Code). •
OWNER /. UaO4t86
❑ I, as owner of the property, am exclusively contracting eoe I
with licensed contractors to construct the project (Sec- MAIL
ADDRES$ ' W P 3
tion 7044, Business and Professions Code). t'�
CONSTRUCTION LENDING AGENCY CITYTEL. NO./.
I hereby affirm that there is a construction lending agency for 1A- b��: 9
the performance of the work.for which this permit is issued' CONTRACTOR 0
PS
(Sec. 3097, Civ. C.). •- - -
ADDRESS
Lender's Name c
CITY PTEL. NO.
LAtnder's Address STATE ry C% LIC.
I certify that. I have read this application and state that the LICENSE NO. S 7— 6 Z 6 CLASS
above information is correct. I.agree to comply with all County
ordinances and State laws relating to building construction, e ,
and hereby authorize representatives of this County to enter
upon the above-megtioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
.r�C2� _ �� Vis— �{_.— � � , • •
Signature of Applicant or Agent Date