HomeMy Public PortalAbout9058 ACASO DR_Mechanical_9/18/1986 WORKERS' COMPENSATION DECLARATION �, APPLICATION FOR .PERMIT
I her if�t that I have a certificate of consent to self
insure r a c@rtificate of Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
or a r tified 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 county building inspec- FOR APPLICANT TO,FILL IN BUILDING
ADDRESSy�`J O �� / i C.Qa5d
tion department. (PRINT OR TYPE ONLY)
Date Applicant LOCALITY /�
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
^ c
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE I CROSS ST. L
ABSORPTION UNIT, BTU DISTRICT NO. P SSED Y
(This section need not be completed if the work involved by
the permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT, CFM O
I certify that in the performance of.the work for which this [ 0
permit is issued, I shall not employ any person in any manner
so as To become subject to the Workers'Cown Tio ws. BOILER, BTU APPROVALS DATE INSPECTOR'S SIGNATURE
r
Date 9-11 � Applicant COMPRESSOR, BTU ROUGH
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL 1p
Exemption, you should become subject to the Workers'
Compensation provisions of The Labor Code, you must forth- EVAPORATIVE COOLER -DAT- 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 O ,�
(commencing with Section 7000) of Division 3 of the Business
and Professions Code, and my license is in full force and effect. CL
O
License Number Lic. Class ► V
Contractor Date O
i•�
❑ I am exempt under Sec.
Plan check fee W
B.BP.C. for this reason'
Date: PERMIT ISSUING FEE $ Z
T
Signature OTAL FEE
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): 2546 4 A
I, as owner of the,property, or .my employees with ADDRESS
\ wages as their sole compensation,will do the work and # e 0 0 0 0 8
CITY TELNO
the structure is not intended or offered for sale(Section . .
:I .� ® 2Q50
7044, Business and Professions Code).
OWNER o 0 o20,505
ElI, as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec- MAIL
tion 7044, Business and Professions Code). ADDRESS �.9, 8-$6
CONSTRUCTION LENDING AGENCY CITY TEL. NO.
I hereby affirm that there is a construction lending agency for ,
the performance of the work for which this permit is issued CONTRACTOR
(Sec. 3097, Civ. C.).
ADDRESS
Lender's Name
CITY TEL. NO.
Lender's Address
STATE .LIC.
I certify that l have read This application and state that the LLICENSE 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
n the ave n d property for inspection urposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
o
Signature of Applicant or Agent Date - .