HomeMy Public PortalAbout4868 ARDSLEY DR_Mechanical__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
herebT affirm that I have a certificate of consent to self
'insure, or.a certificate of Workers'Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof (Sec. 3800, Lab. C.) 76A364C
✓Al CE-818(REV. 10/81)
Policy No Certified
ykg! Company Sd. F COUNTY OF LOS ANGELES BUILDING AND SAFETY
® Certified copy is hereby furnished.'
❑ Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING 1`�� n S
tion department. ADDRESS(PRINT OR TYPE ONLY) / O !7
Date �6 Applicant����/'`� � LOCALITY �/^� qr y(� •
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST.
(Z,, r
(This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO,
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
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 INSPE TOR'S S TURE
Date Applicant COMPRESSOR, BTU t�faN 0 ROUGH
NOTICE. TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers'
Compensation provisions of the'Labor Code, you must forth- EVAPORATIVE COOLER ALIDAT 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 ! v
(commencing with Section 7000) of Division 3 of the Business (�
and Professions Code, and my license is in full force and effect.
_ d
License Number Lic. Class G oil.i�ef- .�E 9 �� rY
Contractor S= Date o
❑ I am exempt under Sec. LU
Plan check fee CL
B.BP.C. for this reason N
Date: 91171
S_,�_ PERMIT ISSUING FEE $ 11U1z
I
Signature /�. rAft4,_ G TOTAL FEE
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby ffirm that I am exempt from the Contracto 's License ►
Law for th following reason (Section 7031.5, sines, and NAME
Professions e):
❑ I, as own of the property, or. employees with ADDRESS
wages as the sole compensatio will do the work and
the structure is of intended Sv ffered for sale(Section CITY TEL. NO.
7044, Business a Profess dns Code). � 7�
OWNER�I�i'CAlf`� ¢L � / C R %r ✓' CIA1/ il,81V
❑ I, as owner of the pr rty, am exclusively contracting �i a
with licensed contr to to construct the project (Sec- ADDRESS d -S
tion MA
7044, Busin sand Pr scions Code).
CONST CTION LEND AGENCY CITY -Te �.,,� p C/ l TEL. NO. .S.7 ® ° a 3 Q 5 0 x
I hereby affirm t there is a construct) lending agency for
the Performa of the work for which t ermit is issued CONTRACTOR /4/// �+� Ile f71�'/V(o CUp,o�r'Nf' ' 9. 1 �l."8 8
(Sec. 3097 e
Iv. C.). fj
ADDRESS ✓y C -Al / R J_
Lender's Name
Lender's Address CITY R Os 0.4v o 4<i TEL. NO. � �j 14/13-3
STATE J r- LIC. `j a y'►
1 certify that I have read this application and state that the LICENSE NO. �/ l� (�S CLASS o� V
above information is correct. I agree to comply with all County
ordinances and State laws relating to building construction,
and hereby authorize rep{esentatives of this County to enter
upon the abo -menti ' d property for inspect' n urp sec. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date