HomeMy Public PortalAbout9441 1/2 - 9445 1/2 LAS TUNAS DR_Mechanical_7/12/1988_compressor and toilet exhaust fan WORKERS',COMPENSATION DECLARATION APPLICATION FOR PERMIT
1',,hOeby affirm that I have a certificate of consent to self
-Insure, or a certificate'of Workers'Compensation Insurance, ,eAse4c HEATING - VENTILATING - AIR CONDITIONING
••-^ora Cdrtified copy thereof (Sec. 3800, Lab. C.)
CE-818(REV. 10/81)'
olcy.No.e ei.isa Company i�ftL. (onM�
Certified copy is hereby furnished. COUNTY OF LOS ANGELES' B I ING AN AFETY
Certified copy is filed with'the county building inspec- FOR APPLICANT TO FILL IN BUILDING
tionepartmerit. " (PRINT OR TYPE ONLY) ADDRESS
Date Applicant / ems" NO. LOCALITY
TYPE OF APPLIANCE OR EQUIPMENT FEE
CE TIFICATE 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($100)or less.) -
AIR HANDLING UNIT,.CFM
I certify that in the performance of the work for which this permit
permit is.issued, I shall not employ any person in any manner
so as to become subject to the_Workers''Compensation LOWS. BOILER, BTUAPPROVALS DATE NSP CT R'S SIGNA RE
//
Date Applicant COMPRESSOR, BTU 4 bC),DD0 ROUGH
i
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: FAY 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.
T EXR- . FM V
0
License Number ��L Lic. Class
Contractor " kJV1tiv"Ja6,e f I(Z Its 01 4 .3A o
❑ I am exempt under Sec. Kan check fee #io;o 0.0:0 8 UJ
= � �•
B.&P.C. for this reason
Date: !, H
PERMIT ISSUING FEE $ .V '1 -,1'4 Q-5 0 Z
Signature TOTAL FEE 0 0 1 4 Q5 0 5
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that 1 am exempt from the Contractor's License - ► O 7, 1'2,.-8 8
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)."
OWNER o L
❑ 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
CONSTRUCTION LENDING AGENCY CITY .-vpl�. -ry 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 L,
(Sec. 3097, Civ. C.).
ADDRESS
Lender's Name $I
LSTA
Y. O DOD TEL. NO. 1 -
Lender's Address ' �j
TE LIC.
I certify that I have read this application and state that the ENSE NO. CLASS- �o -
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 abo y e-mentioned property for inspection purposes,: . SEE REVERSE FOR EXPLANATORY.LANGUAGE.
Signature of Applicant or Agent Date