HomeMy Public PortalAbout10781 BLACKLEY ST_Mechanical__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
I hereby _d"m �thaf Y have a certificate of consent to self
Insure, or a certificate of Workers' Compensation Insurance, 76A364C HEATING - VENTILATING - AIR CONDITIONING
or a certified copy-thereof (Sec. 3800, Lab. 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 c ty,building inspec- FOR APPLICANT TO FILL IN BUILDING
tion department. ADDRESS
Date 12- ` (PRINT OR TYPE ONLY)
Applicant LOCALITY
NO TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST
(This section need not be completed if the work involved by ABSORPTION UNIT, BTU v DISTRICT NO PROCESSED BY
the permit is for one hundred dollars (;100)or less:) f
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 IN PECTO 5 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 VALIDATI N
with.comply with such provisions or this permit. shall be
deemed revoked. FURNACE F GRAVITY-
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER SUSPENDED—UNIT—
(commencing
USPENDEDUNIT(commenting with Section 7000) of Division'3 of the Business WALL
and Professions Code,and my license Is in full force and effect (�uCT CtJT�n
�J �
License Number -3 qZ/ Lic. Class , V
Contractor Date O
I am exempt under Sec W
Plan'check fee h
B.BP.C. for this reason Date PERMIT ISSUING FEE $ 050 Z
Signature TOTAL FEE SQ
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT —43624 A
I hereby offirm,that I am exempt from the Contractor's License ,
Law for the following'reason (Section 7031 5, Business and NAME # e o 0 0 0 8
Professions-Code) ADDRESS 1 0 0 2 0.5 0
I, as owner of-the property, or my employees`with o -o�0 2 Q 5 O 5
wages as their sole compensation,will do the work and "
CITY TEL NO
the structure Is not intended or offered for sale(Section
2-0 9-8 5
7044, Business and Professions Code) f))
❑ OWNER C. //2#1-2C12 e—X4I, as owner of the'property, am exclusively contracting- ��++ / �Q s
with licensed contractors to construct the project (Sec- ��lJ /v�
WAIL
tion 7044, Business and Professions Code) /
ADDRESS !
CONSTRUCTION LENDING AGENCY, CITY 7e, ld& TEL NO STS OYS?/
1 hereby affirm that there is a construction lending agency for ,
the performance of the work for which this permit Is Issued CONTRACTORrJ� � Cd�)SLE3�
(Sec. 3097, Civ C.).
Lender's Name
ADDRESS
'
Lender's Address /�,/
CITY lGr(CJS`J � TEL NO
I certifythat I have read this application and state that the STATE LIC f
pp LICENSE NO S` `� CLASS /
above Information is correct. I agree to comply with all County -
ordinances and State jaws relating to building construction,
and hey authorize representatives of this County to enter '
upon the/above-mentioned property for inspection purposes. SEE REVERSE'FOR EXPLANATORY LANGUAGE
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" i
Signature of Applicant or Agent Date - "