HomeMy Public PortalAbout4850 WILLMONTE AVE_Mechanical__ J WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
'��(sure of'.ffi`r�m�i�cate of Workers'Compense of ation lnsuranCnt to elf
;' p 76g36AC HEATING - VENTILATING - AIR CONDITIONING
or a cer led copy thereof(Sec. 3800, Lab. C.) 76-818(REV. 10/e1)
Policy No.—Company
Q Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
E.
Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING r►D
tion department. (PRINT OR TYPE ONLY) ADDRESS (J CJ
Date Applicant LOCALITY /
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST j 1� — z
COMPENSATION INSURANCE CROSS ST. �[ /
(This section need not be completed if the work Involved by ABSORPTION UNIT, BTU DISTRICT NO. PROCESSED BY
the permit is for one hundred dollars($1100)or less.)
AIR HANDLING UNIT,CFM
I certify that in the performance of the work fo.wh'•h this
permit is issued, I shall not employ any persc manner BOILER, BTU
so as to become subject to the Workers' Ion Laws. APPR LS rDATEINSP ISNAT E
COMPRESSOR, BTU dF7d ROUGH Date r pplicant NOTICE ff0 PPLICANT: If, of m ing/f isCertif to of VENTILATION SYSTEM FINAL
Exemption, you should become subject to th okers'Compensation provisions of the Labor Code, yo ust forth- EVAPORATIVE COOLER L
with comply with such provisions or this pe it shall be
deemed revoked. � FURNACE: FAU—GRAVITY n ".)
LICENSED CONTRACTORS DECLARATION FLOOR BTU 0 UO
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED—UNIT—
'(commencing
USPENDED UNIT'(commencing with Section 7000) of Division 3 of the Business WALL
and Professions Code,and my license is in full force and effect.
. O
License Number Lic. Class /)
(f10>
Contractor Date
❑ I am exempt under Sec. :2 7 1 7.8 A
Plan check fee IL
BAP.C. for this reason'
PERMIT ISSUING FEE$ # 0 0 0 0 0 8
Date:
TOTAL FEE I 0 - 44.50
Signature
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 / —b LjF� ® o 0 0 4 4,5 0
Professions Code): "
i
El 1, as owner of the property, or my employees with ADDRESS ��'� EVI �•� 0604-87
wages as their sole compensation,will do the work and
the structure is not intended or offered for sale(Section CITY ��.? e NO: ;
7044, Business and Professions Code).
OWNER
s 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 P
(Sec. 3097, Civ. C.).
ADDRESS
Lender's Name
CITY TEL. NO.
Lender's Address
I certifythat I have a lication and state that the STATE LIC.
pp LICENSE NO. CLASS
above informatio ire , I agree to comply with all County
ordinances anTie I s relating to building construction,
and hereby ori repr sentatives of this County to enter
upon the e- ntio) 7pertREVERSEy for inspect' n purposes. SEE FOR EXPLANATORY LANGUAGE
vv v
Signature of Applicant o nt ate