HomeMy Public PortalAbout5309 BARELA AVE_Mechanical__ „ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
I hereby affirm that I have a certificate of consent to self
insure, or a certificate'of Worke'rs'Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
CE-81
or a certified copy thereof (Sec. 3800, Lab. C.) C
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
tion department. (PRINT OR TYPE ONLY) ADDRESS
Date Applicant LOCALITY-7:;
/-e'
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE
CROSS ST. '
ABSORPTION UNIT, BTU DISTRICT NO. PROCE ED BY
(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 V 4
I certify that in the performance of the work for which this �a D
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 INSPECTOR'S SIGNATURE
Date Applicant COMPRESSOR, BTU l✓ `^ ROUGH -1- r9
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL r r
Exemption, you should become subject to the Workers' / ' i
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VA•LIDATIO
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAUGRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU a0 -`
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED-UNIT-
'(commencing
USPENDED UNIT'(commencing with Section 7000) of Division 3 of the Business WALL
and Professions Code,and my license is in full force and effect. G
CJ O
License Number Lic. Class ,
I=
Contractor Date
S--
❑ I am exempt under Sec.
�
a
B.BP.C. for this reasonPlan check'fee
Date: �
PERMIT ISSUING FEE $
Signature
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT TOTAL FEE
I hereby affirm that I am exempt from the Contractor's License ,
Law for the following reason (Section 7031.51 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 .,.__._...,...,
❑ 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 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 j
Lender's Name
CIT•V TEL. NO.
Lender's Address AM -
STATr y U 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
the above- entionec! operty for inspec ion purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signa /re of Applicant or Agent D to