HomeMy Public PortalAbout9915 DUFFY ST_Mechanical__ WORKS'COMPENSATION DECLARATION Qpp�����DO� FORIl"151I�I1V11� ll
I hereb'baa_ rm that I have a certificate of consent to self
insure, or a certif tate of Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
,�o certified copy thereof (Sec. 3800, Lab. C.) CE-8]8 N
�•-�, .,,_ -D CE-818(REV. 10/81) "
/Fol icy NoCompany f7LE/�ON� �f-Aqi.'
❑ Certified copy is hereby furnished. COUNTY OF LOS-ANGELES' BUILDING ARID SAFETY
Certified copy is filed with,the county building ins FOR APPLICANT TO FILL IN - BUILDING
tion departmec/nt. - (PRINT OR TYPE ONLY) ADDRESS <77 7C
Date / Applicant LOCALITY �e /� C [
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 DISTRICT NO. PROCESSED BY
the permit is for one hundred dollars($100)or less.)
AIR HANDLING UNIT, CFM
I certify that in the performance of the work'for which this �J[
permit is issued,-I shall not employ.any'person in any manner
BOILER, BTU
so as to become subject to the Workers'Compensation Laws. APPROVALS DATE AlfECTOR'S SIGNATURE
I COMPRESSOR,BTU bco a(/ ROUGH
Date Applicant
NOTICE'TO'APPLICANT:-If,"after making this Certificate of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION
with comply .with such provisions or this permit shall be
deemed revoked. FURNACE: • FAU QHAAVITY�
. . LICENSED CONTRACTORS DECLARATION FLOOR. BTU 7 If -
I hereby affirm that I am licensed under provisions of Chapter9 HEATER: SUSPENDED- UNIT
(commencing with Section 7000) of Division 3 of the Business WALL
and Professions Code,and my'lice'nse.is.in'full force'and efffft:
O
Jec
License Number ` 0J$ C 2 S Lic Class O
(e,
,,�� �]- gyp^-, _ •
V
Contractor tOCJIVl�s� ISL ` [/C- Date I 'f7' " D 0
�384,0A v
❑ 1 am exempt under Sec. # o o.o 0 a 8
Plan check fee w
B.&P.C. for this reason PERMIT ISSUING FEE"$ ° 3 0 5 0 Z
Date:
Signature TOTAL FEE o o 3 0.5 0 5
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT. 0 L 1 5-86
1 hereby affirm that I am exempt from the Contractor's.License D
Law for the following reason (Section 7031.5, Business and NAME
Professions Code):
❑ I, as'owner of the.property, or my employees with ADDRESS
..wages as their sole compensation,will do the work and' 1. -
the structure is not intended or offered for sale(Section CITY. TEL. NO.
7044, Business and Professions Code).
OWNER
❑ ,I, as owner of the property, am exclusively contracting MAIL /C
with licensed.contractors to construct the project.(Sec- ADDRESS
tion 7044; Business and Professions Code).' ()
CONSTRUCTION LENDING AGENCY CITY ems. e[' TEL. NO.
Thereby affirm that,there is a construction lending agency for
the performance of the work for which this permit is issued CONTRACTOR N"0 CL
(Sec. 3097, Civ. C.).
-ADDRESS �C 7( �N ..t
Lender's Name {. yC C�~r '/C
CITY [� TEL. NO. `1✓�a ��"z�
Lender's Address -
STATE [f LIC.
I certify that I have read this application and state that the LICENSE NO. [V 37,3'• 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 above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE_-
Signature of Applicant or Agent - Date