HomeMy Public PortalAbout9995 BOGUE ST_Mechanical__ AOROMI'PENSATION DECLARATION APPLICATION ,FOR PERMIT
jl4`.f`-,rsbyV,%ff' hat I Aave a certificate of,consent to self
In�urp, or a certificate of Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof (Sec. 3800,•Lob. C ) 76A364C
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 co n building inspec- FOR APPLICANT TO FILL IN BUILDING
tion department' ADDRESS
p (PRINT OR TYPE'ONLY) �
�y� LOCALITY
Date `"' �/"�7lpplican
NO •TYPE OF APPLIANCE OR EQUIPMENT � FEE
CERTIFICATE OF EXEMPTION F OM WORKERS' NEAREST r
COMPENSATION INSURANCE CROSS ST
ABSORPTION UNIT, BTU DISTRICT NO PROCESSED BY
(This section need,not be completed if the work involved by
the permit is for one hundred dollars ($100)or less.) CFM
I certify that in the performance-of the work for which this AIR HANDLING UNIT, joy
permit is issued, I shall not employ any person in any manner BOILER, BTU
so as to become subject to the Workers'Compensation Laws APPROVALS DATE INSPEC OR'S 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 VALIDAT N
with comply' with such provisions or this permit shall be
deemed revoked FURNACE. FAU G VITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU Rldd
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. IL
License Number 6 t_� Lic Class O U
09
0
Contractor � .�fly�_ Date O
H
❑ I am exempt under Sec
Plan check fee . . 0.
h
B.&P.0 for this reason - PERMIT ISSUING FEE $ ja I 14° a Q
Date: /-�
Signature
TOTAL FEE
O ER-B DER ECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License Poo.Law for the following reason (Section 7031 5, Business and NAME /�Ci� Ci V !
Professions Code)-
E] 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
E] 1, as owner of the property, am exclusively contracting !
MAIL
with licensed contractors to construct the project'(Sec 91?�Jr ;
tion 7044,*Business and Professions Code) ADDRESS
CONSTRUCTION LENDING AGENCY CITY
I hereby affirm that there Is a construction lending agency for TEL NO,;?3 ,
the performance of the work for which this permit is issued CONTRACTOR '
(Sec. 3097, Civ. C.). /V /
ADDRESS ��
Lender's Name '
CITY
..TEL NO
Lender's Address ry
STATE LIC '
11 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 herebauthorize representatives of this County to enter
upori h o e-mentioned property for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
Ignatu of Applicant or.Agent Date •-
\1 I