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HomeMy Public PortalAbout9553 BLACKLEY ST_Mechanical__ WdRKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT _ �Y affirr?i that I have a certificate of consent to self , or a-ci rtificate of-Workers' Compensation Insurance, t o rtified copy'fh e f Se 3800, Lab C.) 7eA3e4c HEATING - VENTILATING - AIR CONDITIONING w 3 y �� / �n CE-818(REV. 10/81) Polic No. ✓ Company ❑ l7`/4D 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 2 /� �f/?'J tion department. ADDRESS /� (PRINT OR TYPE ONLY) Date Applicant 9Ar.9vX1e $t175, LOCALITY 7`z-,.i1,*14 �' r NO TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST COMPENSATION INSURANCE CROSS ST O✓n:2,4 y (This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO PR Y the permit is for one hundred dollars($100)-or less.) AIR HANDLING UNIT, CFM L9 t certify that in the performance of the work for which this - _ 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 INSP CTOR'S SiURE Date Applicant COMPRESSOR, BTU ROUGH ! NOTICE TO APPLICANT- if, after makmg'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 VALIDAT N with comply with such provisions or this permit shall be deemed revoked 4, FURNACE. FAU GRAVITY-^ LICENSED CONTRACTORS DECLARATION FLOOR BTU I hereby affirm-that I am licensed under provisions of Chapter 9 1 HEATER SUSPEND UNIT %© I (commencing with Section 7000) of Division 3 of the BusinessWALL :Z:ra and Professions Code,and my license is in full force-and effect CL License Number iC/27�7� Lic. Class , V 3aAr/,T,Q 16,01" ' .Z �/ �L O Contractor Date I am exempt under Sec uVi Plan check fee IL B.&P.0 for this reason - PERMIT ISSUING FEE $ G Z Date:' Signature TOTAL FEE Q OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT ;2 4 0 9,6 A I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031 5, Business and NAME # ®i° • e o 8 Professions Code)• ❑ I, as owner of the property, or my employees with ADDRESS �,� 2 Q 5'0 wages as their sole compensation,will do the work and CITY TEL NO the structure is not intended or offered for sale (Section °'' -.2,0506 7044, Business and Professions Code) ; ❑ 0 2 2 4- 8 6 I, as owner-of the property, am exclusively contracting OWNER , with licensed contractors to construct the project (Sec- MAIL tion 7044, Business and Profession's 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 Lender's Name CITY TEL NO._... _ l+erider's Address STATCENE LIC I certify that I have read this application and state that the LISE 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 upo the abov - entioned property for inspection purposes, SEE REVERSE FOR EXPLANATORY LANGUAGE z 9� Signature of Applicant or Agent Date - - -