HomeMy Public PortalAbout8766 BURGHARDT RD_Mechanical__ WORKERS'COMPENSATION DECLARATION APPLICATION
PPLL ICA TION FOR PERMIT
I hereby affirm that I have a certificate of consent to self P9 PY Ytl �V� _
insure, or a certificate of Workers' Compensation Insurance, 7aA3e4C - HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof (Sec. 3800, L?b. C.j 'CE-818(REV. 10/6I) r �y
Q cyCer eC herebypan
't COUNTY OF LOS ANGELES . / ` BUILDING AND SAFETY
Certified copy is hereby furnished. r
❑ 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 1
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' - NEAREST
COMPENSATION INSURANCE CROSS ST.
(This saition need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NQ PROCESSED BY
the permit is for one hundred dollars ($100) or less.) AIR HANDLING UNIT, CFM G
I 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 INSPECTOR'S SIGNATURE
Date Applicant - COMPRESSOR, BTU (J ROUGH 12 oo w,,..
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 VALIDATION
with comply with such provisions or this permit shall be
deemed revoked.. FURNACE: - EAU V GRAVITY -
LICENSED CONTRACTORS DECLARATION FLOOR BTU /0
I hereby affirm that I am licensed under provisions of Chapter 9HEATER: SUSPENDED UNIT_'(commencing with Section 7000) of Division 3 of the Business WALL �
_and Professions Code,qand
�rmyly license is in full force and
-effect. d
/ license Number_! ! J 34 Lii}c Cl.. 19
� -• D
1 Contractor 6ottr�/J O
` ❑ V
am exempt under Sec. W
Plan check fee d
B.BP.C. for this reasonDate: N
' PERMIT ISSUING FEE $ D C) Z
TOTAL FEE • (>
Signature •2 7.8 0.8 A
N
OWNER-BUILDER DECLARATION PLACHECK APPLICANT - #rs e•e e • 8
1 hereby affirm that I am exempt from the Contractors License D 2 o e 3 0 50
Law for the following reason (Section 7031.5, Business and NAME - - ,
Professions Code): - 5
❑ I, as owner of the property, or my employees with ADDRESS -e.eo 3 Q 5 Q
;
wages as their sole compensation, will do the work andCITY TEL. NO. '1 227--83
the structure is not intended or offered for sale(Section
7044, Business and Professions Code).
El1,
1, as owner of the property, am exclusively contracting �C O
with licensed contractors to construct the project (Sec- MAIL ( Q
' lion 7044, Business and Professions Code). -
ADDRESS 4
CONSTRUCTION LENDING AGENCY - CITYTEL. NO. - -
I hereby affirm that there is a construction lending agency for 169
the performance of the work for which this permit is issued CONTRACTOR p lQe D
(Sec. 3097, Civ. C.).
ADDRESS �.
Lender's Name �Q /n/�� �R ~� •.� r
.. CITY TEL NO. A-3
Lender's Address
$TATE `, LIC.
certify that have read this application and state that the LICENSE NO.T 7 CLASS
above information is correct, I agree to comply with all County .
ordinances and State lows relating to building construction,
and hereby authorize represe es of this County to enter - '-
upo he ave-menti ne p ty f inspecIy
tion purpos s. SEE REVERSE FOR EXPLANATORY LANGUAGE
So,oture of Applican or Agent