HomeMy Public PortalAbout5023 ARDEN DR_Mechanical__ n, @�2KERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
I Ireby`affirm that I have a certificate of consent to self .�f
insure,'or'o certific5te of Workers' Compensation Insurance, CE-81 C HEATING - VENTILATING - AIR CONDITIONING /1I(��
or a certified copy thereof (Sec. 3800, Lab. C.)
CE 816(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
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST B
COMPENSATION INSURANCE CROSS ST. �--
(This section need not be completed if the Work involved by ABSORPTION UNIT, BTU DISTRICT NO. OCESSED BY
the permit is for one hundred dollars ($100)or less.) (/
I certify that in the performance of the work for which this AIR HANDLING UNIT, CFM 5( X
permit is issued, I shall not employ any person in any manner U
so as to become subject to the Workers'Compensation Laws. BOILER,'BTU APPROVALS DATE I ECT R'S SIGNATURE
�{
Date i I Applicant——1m WO�l COMPRESSOR, BTU ROUGH
NOTICE tO APPLICANT: If, after making this Certifica e'of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDAT N
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU
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 _Lic. Class V
CC�o--ntractolI I_1 WotU 6r Date—7
IhLI I am exempt under Sec. ;201 S 9 A u
�tTT Plan check fee A.
A.
B.&P.C. for this reason t� PERMIT ISSUING FEE $ # o -o o • o8 z
Date: � jf
Signature TOTAL FEE •o - 20.50
OWNE DE ARATJ PLAN CHECK APPLICANT _
I hereby affirm th exempt from the Contra or's License pop
0 0 0 2.Q 5 v
Law for the followi reason (Secti n 703 , Business and NAME O 71 3-.18 8
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) _
OWNER N 1, as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec- MAIL
tion 7044, Business and Professions Code). ADDRESS
CONSTRUCTION LENDING'AGENCY CIT &M j�� (!A--% TEL. NCl44--�:> j t
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.). Kim wc)6�cn PL13 6)
ADDRESS
Lender's Name
CITY Mt l TEL. NO.2 0 '
Lender's Address t
STATELIC.
11 fJ
I certify that I have read this application and state that the LICENSE NO. 1 CLASS
above information is correct. I agree to comply with all County
ordinances and Sate I s elating to building construction,
and hereby authdr' e' tives of this County to enter
upon the a v io ed o erty for insp ctioan purp e . SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent_-"' Date