HomeMy Public PortalAbout5020 ALESSANDRO AVE_Mechanical__ WORKERS COMPENSATION DECLARATION APPLICATION FOR PERMIT
!I hereby affirm that I have a certificate of consent to self
n1s re 9p,dcertificate of Workers Compensation Insurance
or a certified copy thereof (Sec 3800 Lab C 76A364C HEATING - VENTILATING AIR CONDITIONING
)
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
tion department (PRINT OR TYPE ONLY) ADDRESS
Date Applicant LOCALITY
NO TYPE OF APPLIANCE OR EQUIPMENT FEE 7
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 NOPROCESSED BY
the permit is for one hundred dollars ($100)or less ) (/
AIR HANDLING UNIT CFM �� o
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 Compensat n Laws BOILER BTU APPROVALS DATE INSPE OR 5 SIGNATURE
Date/ -��Apphcant
Date/ COMPRESSOR BTU ROUGH
NOTICE TO APPLICANT If after making this Certifi to of VENTILATION SYSTEM FINAL
Exemption you should become subject to the Workers
Compensation provisions of the Labor Code you must forth EVAPORATIVE COOLER VALIDATI N
with comply with such provisions or this permit shall be
deemed revoked FURNACE FAUGRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER SUSPENDED U IT Q�
(commencing with Section 7000) of Division 3 of the Business WALL 41
and Professions Code and my license is in full force and effect >'
IL
O
License Number Lic Class ► V
OC
Contractor Date O
H
U
I am exempt under Sec W
Plan check fee 9 3 8 Q 0 A H
B 8P C for this reason 'PERMIT ISSUING FEE $ z
Date
Signature
TOTAL FEE # $
OWNER BUILDER DECLARATION PLAN CHECK APPLICANT ( o - 2050
j hereby affirm that I am exempt from the Contractor s License
Law for the following reason (Section 7031 5 Business and NAME o 20505
Professions Code) I
O
El ADDRESS 1 1 8 6
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 CITY TEL NO 0_
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 .J Q r2 d
CONSTRUCTION LENDING AGENCY CITY2!:: T L 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 )
a �
ADDRESS, Q M
Lender s Name
r C
C
IT EL NO S
Lender s Address
LIC
I certify that I have read this application and state that the CrSS
above information is correct I agree to comply with all County
ordinances and State laws relating to building construction
and hereby authors representatives of this County to enter `
up abov coned property for Inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date
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