HomeMy Public PortalAbout5013 WILLMONTE AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION I APPLICATION FOR PERMIT
- I•:here�y affirm t g�, I have a certificate of consent to self
`Trisure, or$certific a of Workers'Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof(Sec. 3800, Lab. C.) CE-81 C
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-013 'Mo
(PRINT OR TYPE ONLY)
Date Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY _eilw C
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST AV
COMPENSATION INSURANCE CROSS ST. jh Gc./ e e- 4.x US Q
(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($100)or less.) W
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers' mpens tion LOWS. IBOILER,BTU g� APPROVALS DAT I CTOR'S SIGNATURE /
�7 COMPRESSOR,BTU '/ / Q ROUGH /
Date - 3 2 Applicant
NOTICE TO APPLICANT: If, after making this Certific f VENTILATION SYSTEM FINAL It
"
Exemption., you should become subject to the Workers' IV
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDkrjj
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU GRAVITY ,0��
LICENSED CONTRACTORS DECLARATION FLOOR BTU 0
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED. UNIT
'(commencing with Section 7000)of Division 3 of the Business WALL
and Professions Code,and my license is in full force and effect.
License Number L3—""�rl '' Lic. Cla C � ,
Contracto fe ^s3-� 17 U .Q S' ad
&7725A
❑ I am exempt under Sec. # 000.008 d
Plan check fee
B.&P.C. for this reason' N
Date: PERMIT ISSUING FEE$ 1 - - 39 25 Z
Signature TOTAL FEE Ot . 0 0 3 9.2 5 5
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT 2(( $7
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). OWNERV /� , O
r
❑ I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec- MAIL MAIL5�7 City �^0 4// 'C-
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY P oL 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 1 9?3, we VeI Ael
Lender's Name .965-1* /2--.
1 N 1,41,0a3 7r.5,0 TEL. NO.
• Lender's Address CI
STATE �`� LIC.
I certify that I have read this application and state that the LICENSE NO.2✓4 CLASS
above information is correct. I agree to comply with all County
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter
I on the abo e-mentio ed propert for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Ag Dote