HomeMy Public PortalAbout9042 ACASO DR_Mechanical_10/10/1986 WORKERS' COMPENSATION DECLARATION APPLICATION FOR PERMIT
I hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
or awt:ertified copy'thereof (Sec. 3800, Lab. C.) 76A364C
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 cou ty building inspec- FOR APPLICANT TO FILL IN BUILDING
tion department. (PRINT OR TYPE ONLY) ADDRESS
Date Jry-7/1—S' Applicant 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 4b. PR eSSED BY
the permit is for one hundred dollars($100)or less.) s
AIR HANDLING UNIT, CFM
I certify That in the performance of the work for which this
U
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers'Compensation LOWS. BOILER, BTU APPROVALS DATE INSP CTOR'S SIGNAT RE
Date 1n—lbCOMPRESSOR, BTU ROUGH
"' �' 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 VALIDATION
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.
- -- O
License Number Lic. Class , U
Contractor Date O
t–
❑ I am,exempt under Sec. LU
Plari check fee y
8.8P.C. for this reason PERMIT ISSUING FEE $
Date:
Signature TOTAL FEE j) _�U
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).
❑ WNER.
I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec- MAIL
tion 7044, Business and Professions Code).
ADDRESS P 5 6 0.7 A
CONSTRUCTION LENDING AGENCY CITY TEL. NO.
I hereby affirm that there is a construction lending agency for #,o a o • o
the performance of the work for which this permit is issued CONTRACTOR Pop. ( o - 2 (15.0
(Sec. 3097, Civ. C.).
Lender's Name ADDRESS o 0 0 2 Q 5 0 5-
.
CITY TEL. NO. I O. O `$ C7
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
up eabove-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Si nature of Applicant or Agent Date