HomeMy Public PortalAbout4879 ARDSLEY DR_Mechanical__ d. affirm th COMPENSATION DECLARATION APPLICATION FOR PERMIT
�ereb y affirm that I.have a certificate of consent to self
nsur or a certificate of Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
or p qer d� y ther of (Sec. 3800, qb. C.) r CE-81 C
g(v CE-618(REV. 10/81)
P Ilcy� Company
❑ Certified copy is hereby furnished. - COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with the county building i FOR APPLICANT TO FILL IN BUILDING
tion department. _ ADDRESS
(PRINT OR TYPE ONLY) ,
Date _ Applicantr LOCALITY �.
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
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 NO. PROCESSED BY /
the permit is for one hundred dollars($LOQ)or less.)
r
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws. I BOILER, BTU APPROVALS DATE ECTOR'S SIGN TUBE
COMPRESSOR,.BTU `1 1 C00 ROUGH
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL
Exemption, you should become subject to-the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATI
with comply with suck provisions or this permit shall be
deemed revoked. FURNACE: FAU GRVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9SUSPENDED UNIT �@
'(commencing with Section 7000) of Division 3 of the Business HEATER: WALL (J
and Professions Code,and'my license is in f�u-ll fo ce and effect.
License Number Lic.cClass 8 6 2 2 A v
Contractor I0 ,v Date ,�_ ' too - 8 0
I am exempt under Sec.
Io - 3Q50 Plan check fee
B.BP.C. for this reason' { 00030,5020:
Date:
PERMIT ISSUING FEE$ �J
Signature TOTAL FEE S 12 1 7,`8 7
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 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)..
❑ I, as owner of the property, am exclusively contracting OWNER
with licensed contractors to construct the project (Sec- MAIL
ADDRESS
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY TEL. NO.
I hereby affirm that there is a construction lending agency for " .3
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the performance of the work for which this permit is issued CONTRACTOR �/L �/ /�� ♦-
(Sec. 3097, Civ. C.):
/ r
Lender's Name ADDRESS 3/ C,*��!• A
CITY�h�, r fP �(/ TEL. NO. �l" t�
Lender's Address
STATE / LIC
I certify that I have read this application and state that the LICENSE NO. 0 3 e- 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 -
upon the above-mentiocie rty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
4 t��-13 2-
Signature of Applicant or Agent Date