HomeMy WebLinkAbout1500AWORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self
sure, or a certificate of Workers' Compensation Insurance, 76A3btC
r t' i d coy rgygqgq9f(Sec. 3800 Lab. C.
,� �. ��/ E • 818 (REV.
aollcy No. /Compan
Certified copy is hereby furnished,
q%EEi��
filed with county bu(Iding inspec-
� _/Applican �/F EXEMPTI FROM WORKERS'ENSATION NSURANCE
(Thissrtllon orad not b. completed 1f 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 Business
and Professions Code, and my license is in full force and effect.
License Number �`� Lic. Class Off" -2
Contrac ;`f/If Date /O -A( —5F
1 am exempt under Sec.
B.BP.C. for this reason
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 theirsole compensation, will do the work and
the structure is not Inrended or offered for sale (Section
7044, Business and Professions Code).
❑ I, 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
APPLICATION FOR PERMIT
HEATING - VENTILATING - AIR CONDITIONING
10/81)
V37/�
COUNTY OF LOS ANGELES BUILDING AND SAFETY &(J0, D
FOR APPLICANT TO FILL IN
(PRINT OR TYPE ONLY)
BUILDINGq
ADDRESS,{ D
/h
LOCALITYIP,
J
%
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
NEAREST
CROSS ST.
ABSORPTION UNIT, BTU
DISTRICT NO.
''1
77;:
AIR HANDLING UNIT, CFM
BOILER, BTU
APPROVVAALL-S
DATE
INSPECTOR'S SIGNATURE
COMPRESSOR, BTU
ROUGH
L-{��j6
VENTILATION SYSTEM
FINAL
CST —c •
l
EVAPORATIVE COOLER
,
VALIDATION
- -�
_
f15QOA
�j.....$
I e e f IL % 5
...74,75v
1(1 2 1— 8%
FURNACE: FAU RAVITY / -
FLOOR BTU
HEATER: SUSPENDED UNIT_ -
WALL
Plan check fee
PERMIT ISSUING FEE $ fa J
TOTAL FEE 'Jy S
PLAN CHECK APPLICANT
NAME
ADDRESS
CITY TEL. NO.
OWNER
MAIL
ADORESS19 �.
CITY G TEL. NCO - ' -
CONTRACT
ADDRESS - -
—r
CITY
TEL. O. 9i6STATE—
1I11 q C,
LICENSE NOJlL� / ! CLASS - �-�� Z O
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 -mention d property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
/0-1G4 7
ignolure of Applicant or Agent Dote