HomeMy Public PortalAbout5407 WELLAND AVE_Mechanical__ DEC
TION
a Worm that
I have a cerci cafe of corse APPLICATION FOR PERMIT
r. .►• tiepeby affirm that I have a certificate of consent to self
Insure„or a certificate of Workers'Compensation Insurance, HEATING'- VENTILATING - AIR CONDITIONING
or a certified copy thereof(Sec. 3800, Lab. C.) CE-81 C
CE 81 B(REV. 10/81)
Policy No. . Company COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is hereby furnished.
❑ Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING
tion department.
(PRINT OR TYPE ONLY) ADDRESS
Date Applicant LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST.
(This section need not be completed if the work Involved by ABSORPTION UNIT,BTU DISTRICT NO. PROCESSED BY <V'
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
permit is issued, I shall not employ any person in any manner
so as to become subject to the Wo rs'Compensdtion Laws. BOILER,BTU APPROVALS DATE_, INSP 'S SIGN RE
Datel- 94-483 Applicant COMPRESSOR, BTU 9a. 0 O 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 VALIDATION
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU MITY it
LICENSED CONTRACTORS DECLARATION FLOOR BTU 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 m license is in full force and effect.
y 9 - -
License Number Lic. Class3 2 0,OA 19
Contractor e' -� O
❑ # o.o o 0 0 8 U
I am exempt un er Sec. ( o a 4 a 0 0 LU
B.&P.C. for this reason' Plan Check fee U)
Date: PERMIT ISSUING FEE $ ° ° ° 4 8,0 0�3: z
Signature TOTAL FEE Q o7. 1 5-88
OWNER-BUILDER DECLARATION PLAN 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 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
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 wo}k for which this permit is issued CONTRACTOR
(Sec. 3097, Civ. C.).
ADDRESS •
Lender's Name
CIT TEL NO.
Lender's Address
STATELIC. s
I certify that I have read this application and state that the LICENSE NO. t� CLASS
above information is correct. I agree to comply with all County
ordinances and Statp 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
I- 1LI SSC
Signature of Applicant or Agent Date