HomeMy Public PortalAbout10648 ARROWOOD ST_Mechanical_12/13/1984_Compressor WORKERS'COMPENSATION DECLARATION (� /p� �p FOR
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I herek„ affirm that I have a certificate of consent to self A11 'PUCA � N FOR l�LSII�IIV H
insure, or a certificate of Workers'Compensation Insurance, HEATING = VENTILATING - AIR CONDITIONING
° or a certified copy thereof (Sec. 3800, Lab. C. 76A364C
CE-818(REV. 10/81)
Policy No,4��Company /f _
FJ Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
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�. Certified copy is filed with the'county building inspec- FOR APPLICANT TO FILL IN BUILDING
tion department. ADDRESS
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12,4
(PRINT OR TYPE ONLY)
Date �' '9aptilicant r � � LOCALITY"j
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 involvedbyABSORPTION UNIT, BTU DISTRICT NO. PROC SE 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
permit is issued, I shall not employ any person in any mariner BOILER, BTU
so as to become subject to,the Workers'Compensation Laws: APPROVALS DATE INSP R'S SIGNAT RE
Date Applicant COMPRESSOR, BTU ROUGH f /
NOTICE TO APPLICANT: If, after making This Certificate of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers' A ,1
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VLIDATION
with comply with such'provisions or, this "permit shall be
deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATIONFLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT
'(coinmencing'with Section 7000) of Division'3 of the Business HEATER: WALL
and Professions Code, and my license is in full force and effect.
License Number tJ(.�`9�(�� Lica Class esea� 1,2 2 2 A
D
Contractor o o.o o c 8 t~07
❑ I am exempt under Sec. o,o
Plan check fee 1 2 1 Z
B.&P.C. for this reason' PERMIT ISSUING FEE $
Date:
Signature TOTAL FEE
OWNER-BUILDER DECLARATION/ PLAN CHECK APPLICANT
I he'rebyaffirm that I am exempt from the Contractor's License D
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
fessions Code).
OWNER' M
❑ I, as owner of the property, am exclusively contracting
MAIL
with licensed contractors to construct the project (Sec= ADDRESS
tion 7044, Business and Professions Code)..
CONSTRUCTION LENDING AGENCY CITTEL. NO.
the performance of the work for which this permit is issued CONTRACTORI_ G D.
(Sec. 3097, Civ. C.,).
/. ADDRESS > fir/ 6at_1
Lender's Name 'v
CITY i. t TEL. NO.
Lender's Address
STATE17V LIC.
I certify that I Rave 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-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date -