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Home My Public Portal About5125 ARDEN DR_Mechanical__ ' V P \ WORKERS'COMPENSATION DECLARATION ' APPLICATION FOR. PERMIT I hereif/ affirm that I have a certificate of consent to self ► inNre; or,a certificate of Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING or a`certified copy thereof (Sec. 3800, Lab. C.) CE-818 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 CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST COMPENSATION INSURANCE CROSS ST. `. P (This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO. PROCESSED the permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT, CFM I certify that in the performance of the work for which This � permit is issued, I shall not employ any person in any manner BOILER, BTU so as to become subject to the Workers'Compensation Laws APPROVALS DATE INSP TOR'S SIGNATURE io Date Applicant r COMPRESSOR, BTU © ��d ROUGH NOTICE TO APPLICANT: If, after making 4is Certificate 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: FAU GRAVITY LICENSED CONTRACTORS DECLARATION FLOOR BTU OCA O 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 Thy license is in full force and effect. License Number Zf2LLLic. Class V ®C Contractor Date ❑ I am exempt under Sec. LIA Plan check fee 9L B.&P.C. for this reason' � PERMIT ISSUING FEE $ G Date: TOTAL FEE Signature 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 2 9 7 9,7 A wages as their sole compensation,will do the work and the structure is not intended or offered for sale(Section CITY TEL. NO. # 0 0 0 0 0 8 7044, Business and Professions Code). OWN 2'0'a 3 0,5 0 ❑ I, as owner of the property, am exclusively contracting f with licensed contractors to construct the project (Sec- MAIL tion 7044, Business and Professions Code). ADDRESS a:a-a 3 0.5 0, CONSTRUCTION LENDING AGENCY CITY TEL. NO. i S C n $4 I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued CONTRACTOR S A e Al , (Sec. 3097, Civ. C.). ADDRESS Lender's Name CITY TEL. NO. Lender's Address STATE LIC. I certify that I have read this application and state that the LICENSE NO. CLASS 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-men 0 ty for inspection urposes. SEE REVERSE FOR EXPLANATORY LANGUAGE ��[[ 3 ?'- Signature o Applicant or Agent Date