HomeMy Public PortalAbout4915 ARDEN DR_Mechanical__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
I`hbreby Offirm that I have a certificate of consent to self
insure, or a certificate of Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
or a ce tified copy thereof (Sec. 3800, Lab. C.) 76A364C
r CE-818(REV. 10/81)
01 0. Company
❑ Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with the county buildingL_ FOR APPLICANT TO FILL IN BUILDING / n /)�
tion department. ADDRESS �GCt 1J) (PRINT OR TYPE ONLY)
Date /1—16"Applicant LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS'� NEAREST �� �
COMPENSATION INSURANCE CROSS ST.
17,tef
(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.) j�
AIR HANDLING UNIT, CFM Q
I certify that in the performance of the work for which this �t
i ��/
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws. BOILER, BTU APPROVALS DATE N5 TOR'S SIGN RE
Date Applicant
COMPRESSOR, BTU ROUGH /
17
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM 1 FINAL
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDA
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU G VITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU S
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.
e-14License Number 7 3 5 Lic. Clas'---6 — z 8 4 0.6 A V
Contractor �a�l`➢� Date1L'�L , # 0 0 0 0 0 0
O
❑ I am exempt under Sec. :1 ° 0 2 0,5 0 y
2 0,5(} 1IL
Plan check fee
B.BP.C. for this reason
PERMIT ISSUING FEE $ Z
Signature i 1.20-87-
Date:
TOTAL FEE
�
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
Professions Code):
❑ I, as owner of the property, or my employees with ADDRESS
wages as their sale compensation,will do the work and
the structure is not intended or offered for sale(Section CITY. TEL. NO.
7044, Business and Professions Code).
OWNER J� F i3 e
❑ 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 111.57
CONSTRUCTION LENDING AGENCY CITY r.,,M 116 l f TEL. NO.,,3
I hereby affirm that there is a construction lending agency for.
the performance of the work for which this permit is issued CONTRACTOR �2 ,
(Sec. 3097, Civ. C.).
Lender's Name ADDRESS 1,e
CITY /reTATE TEL. NO. Q J_3 r7 _
Lender's Address ) c aJ
I certify that I have read this application and state that the SI LICENSE NO. d CLASS C
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
rhe ab ve-mentionederty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
//_1109-Ya
Signature of Applicant or Agent Date