HomeMy Public PortalAbout5037ALESSANDRO AVE_Mechanical WORKERS'COMPENSATION DECLARATION
W.! Pp, FOR PERMIT
r insorquorPV I'affirm rconsent
a?cprtif cate tff Workers' Compensation elf
or p•certified copy'thOreof (Sec.3800, Lob. C.) 76A364C HEATING - VENTILATING - AIR CONDITIONING
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 �A9�
tion department. ADDRESS(PRINT OR TYPE ONLY) yyy--W f�
.Date Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY
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 Y
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
so as to become subject to the Workers"Compensation Laws. BOILER, BTU APPROVALS DATE ECTOR'S SIGNATURE
Date Applicant COMPRESSOR, BTU 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 VALIDA ION
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.
License Number Lic. Classpool0
09
Contractor Date O
F
l�
I am exempt under Sec. UJ
Plan check fee 9116
B.BP.C. for this reason ;9 81 6.9 A
Date: PERMIT ISSUING FEE $
Signature
TOTAL FEE # °'° ° �'° 8
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT 1'.o
0 2050
1 hereby affirm that I am exempt from the.Contractor's License ,e
Law for the following reason (Section 7031.5, Business and NAME �� Com}, , ° ° ° 2 0,5 0 c=>
Professions Code):
El 1, as owner of the property, or my employees with ADDRESS �� �� ��� J C22 -87
wages as their sole compensation,will do the work and �` -�
the structure is not intended or offered for sale (Section CITY �� TEL. NO..Z •�(��
7044, Business and Professions Code).
OWNER
I, as owner of the property, am exclusively contracting c�J't7
with licensed contractors to construct the project (Sec- MAIL
tion 7044, Business and Professions Code). ADDRESS
CONSTRUCTION LENDING AGENCY CITY TEL. NO.
I hereby affirm that there is a construction lending agency for Poo.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
I certifythat I have read this application and state that the STATE LIC.
pp LICENSE NO. CLASS
above information is correct. I agree to comply with all County
ordinances and State laws relating to building construction,
and ere y authorize representatives o,J,this County to enter
u e abIon pr perty f r inspection purposes.
/ SEE REVERSE FOR EXPLANATORY LANGUAGE
A �7
Signature of Applicant or Agent Date