HomeMy Public PortalAbout9979 DUFFY ST_Mechanical_11/20/1986 WORKERS' COMPENSATION DECLARATION /p� j�j ^�('/p�—�f(���2� n j� j��/�
I hererby,affirm that I have a certificate of consent to self /Au u. LO'`�/�1�� N FOR I1 EtiU�V T
insure, or.o certificate of Workers' Compensation Insurance, HEATING VENTILATING - AIR CONDITIONING
ora certified copy thereof (Sec. 3800, Lab: C.) 76A364C `
CE-818(REV. 10/81)
Policy No. Company
Certified copy is herfurnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING
tion department. (PRINT OR TYPE ONLY) - ADDRESS _/
LA
LOCALITY
NO.
Date �-� r�pplicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FRO WORKERS'. NEAREST )
COMPENSATION INSURANCE CROSS ST. �C�, k J' .`
ABSORPTION UNIT, BTU DISTRICT N0. PR BY
(This section need not be completed if the work involved 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 . U
permit is issued, I shall not employ any person in any manner BOILERBTU
so as to become ,subject the Workers'Compensation Laws._ _ APPROVALS DATE INSPEC NATURE
�' .� COMPRESSOR, BTU '` ROUGH
Date (&pplicant � 9
NOTICE TO APPLICANT: If, after making is Certificote 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 GRAVITY
LICENSED CONTRACTORS DECLARATION. FLOOR BTU G
hereby affirm that 1 am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
'(commencing with Section 7000) of Division 3 of the Business WALL
and Professioris Code, and my license is in full force and effect. C. -
pn 0F�Z '�
License NumberGoZ•�d X O Lic. Class C 2-
D
Contractor �/b�' Date ��fez �CV
❑ I am exempt under Sec LU
Plan check fee CL
C
B.BP.C. for this reason'
PERNAIT ISSUING FEE $
Da_ate:
TOTAL'FEE
Signature
OW R-BUILDER DECLARATION PLAN CHECK APPLICANT '
I hereby affirm that I am exempt from the Contractor's License D
Law for the following reason (Section 7031.5, Business and NAME I
Professions Code):
❑ - 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
I, as owner of the property, amexclusively contracting
with licensed contractors to construct the project (Sec- MAIL fj
tion 7044, Business and Professions Code). ADDRESS 1�
CONSTRUCTION LENDING AGENCY) J�� 5 9 9 8 A
CITY r TEL. NO: H'
I hereby affirm that there is a construction lending agency for # 0 0 0 0 0 8
the performance of the work for which this permit is issued CONTRACTOR �.
(Sec. 3097, Civ..C.). d GZ D .o 0 4 4,-5.0
ADDRESS
Lender's Name
4450�
CITY TEL. NO. _
Lender's Address p
STATE ' A, LIC.. 'I 1'2 0-8 6
I certify that I have read this applicationand 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 hereby authorize representatives of this County to.enter
upon the abov -meproperty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent. Dote - - "