HomeMy WebLinkAbout7682AWORKERS' COM PEN SAJION DECLARATION
I hereby offirm that I have a certificate of consent to self
insure, or a certificate of Workers' Compensation Insurance,
or a certified copy thereof (Sec. 3800, Lab. c.)
Po4cy No. .10kf �-A4 Company
❑
Certified copy is hereby furnished.
Certified copy is filed with the county building inspec-
tion department.
Date IMP" Apphcont 3ti SIM
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the work involved by
the permit is for one hundred dollars (;100) or less.)
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers' Compensation Laws.
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth-
with comply with such provisions or this permit shall be
deemed revoked.
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Busiress
and Professions Code, and my license is in full force and effect.
License Number " 195932 Lic. Class C- 43
Contractor ,`4]1 11it slm Date 1/22185
❑ 1 am exempt under Sec.
B.&P.C, for this reason.
Date:
Signature
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and
Professions Code):
❑ I, as owner of the property, or my employees with
wages as their sole compensation, will do the work and
the structure is not intended or offered for sale (Section
7044, Business and Professions Code).
❑ 1, as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec-
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued
(Sec. 3097, Civ. C.).
Lender's Name—
Lender's Address
I certify that I have read this application and state that the
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
upon the above-mentioned property for inspection purposes.
1122/85
Signature of Applicant or Agent 'Date
APPLICATION FOR PERMIT
76A364C HEATING - VENTILATING - AIR CONDITIONING
CE - 818 (REV. 10/81 )
Fund COUNTY OF LOS ANGELES Tr, f.11153 -D BUILDING AND SAFETY
Lot 47
FOR APPLICANT TO FILL IN
(PRINT OR TYPE ONLY)
BUILDING
ADDRESS
TXWXWCaili
LOCALITY
NO.
TYPE OF APPLIANCE OR EQUIPMENT
FEE
NEAREST
CROSS: ST.
ABSORPTION UNIT, BTU
DISTRICT NO.
PROCESSED BY
AIR HANDLING UNIT, CFM
BOILER, BTU
APPROVALS
DATE INSPECTOR'S SIGNATURE
COMPRESSOR, BTU
ROUGH
:
VENTILATION SYSTEM'
00
FINAL
�� .- .r �# e
EVAPORATIVE COOLER
Pilo
VALIDATION
•
.r r. 'T� 4
FURNACE: FAU GRAVITY
FLOOR BTU
HEATER: SUSPENDED-UNIT—
WALL—
USPENDED UNITWALLPlan
Plancheck fee
PERMIT ISSUING FEE $
��
��
TOTAL FEE
2
gfi
PLAN CHECK APPLICANT
NAME_ Sli ghost Metal Co. M TaC•
ADDRESS 21 F 11 ])slab its 5 .
CITY Rawatiou Card* VEL. NO. 527.4863
OWNER Prompl y Of So. Calif.
MAIL P.O. 'Rex 19672
ADDRESS
CITY Twine TEL. NO. 660-0660
CONTRACTOR Slui11i rillae;r **! %%tal Co.
ADDRESS 21911 Balshirel St.
CITY 14vnitan GArdei1;1f:EL_ NO. 527-1,1P63
LICENSE NO. - - 32. CLASS
SEE REVERSE FOR EXPLANATORY LANGUAGE