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HomeMy Public PortalAbout9560 BISBY ST_Mechanical__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT I hereby affkm that I have a certlfloate�df consent to self Insure,-or a certificate of Workers' Compensat?on�nsurance, HEATING - VENTILATING - AIR CONDITIONING or a certified copy thereof (Sec. 3800, Lab. C ) CE-818(REV. 10/81) Policy No. Company CertHied copy Is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY ❑ Certified copy Is filed with the county building Irspec- - FOR APPLICANT TO FILL IN BUILDING S y tion department. (PRINT OR TYPE ONLY) _ Date Applicant LOCALLY �I11 P,� E ( T NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF DJCEMPTION FROM WORKERS' NEAREST d ' COMPENSATION INSURANCE CSS ST G V (This section need not be completed If the work Invokved by ABSORPTION UNIT, BTU MSTRICT NO. PRoaSSM BY the permlt Is for one hundred dollars($100)or less.) , /�� I cerlNy that In the performance of the work for which this ^IR HANDLING UNIT,CFM L/ Pe[mlt Is Issued, I shall not employ anyperson In any manner to ars s to be-come subject to the Work BOILER, BTU AMOYA S DATE orx's T� Z Dote 'Qrt- App cant COMPRESSOR, BTU ROLGH NOTICE TO APPLICANT: If, after makingIO this Certificate of VENTILATION SYSTEM FINAL Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- VALIDATIONEVAPORATNE GOOIER with comply with such provisions or this permit shall be deemed revoked. FURNACE: FAU GRA LICENSED CONTRACTORS DECLARATION FLOOR BTU ( V I hereby affirm that I am licensed under provislons of Chapter 9 HEA SUSPENDED I Nrr h `(commencing with Section 7000) of Division 3 of the Buses WALL and Professions Code,and my license Is In full force and effect. t 1 License Number w7``�y If ✓� Llc. Class( i � 51 2 5 A Ix 0 cantaotar a aa( � , eos ❑ I am exempt under Sec. p Plan check fee I'° 2 Q 5 0 y B.BP.C. for this reason PERMIT ISSUING FEE $ 0. 0 ! (� 2 Q 5 0 6 0 Date: Signature TOTAL FEE 0 •j 2 4 i $6 OWNER-BUILDER DECLARATION PLAN CHEF APPL"Iff I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and NAME D )M C + Professions Code): �y^ ❑ I, as owner of the property, or my employees with ADDRESS16 Ig 0/yI E wages as their sole compensation,will do the work and TEL the structure Is not Intended or offered for sale(Section 7044, Buslness and Professlons Code). A ❑ � (j'I, as owner of the property, am exclusively contracting OV�t� PA 7 with licensed contractors to construct the project (Sec- SSS s tion 7044, Business and Professions Code). n CONSTRUCTION LENDING.AGENCY qTy TEL No.SW P-©6 '/ I hereby affirm that there Is a construction lending agency for the performance of the work for which this permit Is Issued CXIINT ZACTOR ' (Sec. 3097, Civ. C_). ADDRESS Lenders Name Lender's Address CITY W-N b TEL NO. Q 3 b ST I certify that I have read this application and state that the LkZE SE NO. 3 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 th bo e o for Inspection purposes. SEE REVERSE FOR-EXPLANATORY LANGUAGE �- �00P Signature of Applicant or Ag*nt Date ..