HomeMy Public PortalAbout8853 ELM AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION n nnt( C n�� N FOR n2RMT
I hereby affirm That I have a certificate of consent to self - h11T IT L� G�1 I1G Ili I!—LSll�tll`V'll
insure, or a certificate of Workers' Compensation Insurance, - HEATIIbG - !lEibTILATIidG - AIS COW'DITIOV�IfVG
or a certified copy thereof (Sec. 3800, Lab. C.) 76A364C
CE-818(REV. 10/81)
Policy No. Company
Certified copy is hereby furnished." COUNTY OF LOS ANGELES' BUILDING AND SAFETY
❑ Certified copy isfiled with the county building inspec- FOR APPLICANT TO FILL IN BUILDING
tion department.
(PRINT OR TYPE ONLY
Date ApplicantLOCALITY f
NO. TYPE OF APPLIANCE OR EQUIPMENT - FEE C.�
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.) 1^ /
I certify that in the performance of the work for which this AIR HANDLING UNIT, CFM CO/
permit is issued, I shall not employ any person in any manner BOILERBTU t
so as to become subject to the Workers'Compensation ,.Laws. _ APPROVALS - DATE INSPECTOR'S SIGNATURE
Date Applicant COMPRESSOR, BTU ROUGH 3-30 0
NOTICE TO APPLICANT: If, after making fhis'Certificate'of VENTILATION SYSTEM FINAL �f �✓
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
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.
O
License Number tic..Class D
Contractor Date o
❑ I am exempt under Sec.
Plan Check fee d
Ul
B.&P.C. for this reason- �
PER
Date: flflIT ISSUING FEE $
TOTAL FEE
Signature
OWNER-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 '
rofessions Code):
Agr 19NI, as owner of The property„ or my employees with ADDRESS
wages as their sole compensation,will do the work and t �, 7 ? A
the structure is not intended or offered for sale.(Section CITY TEL. NO. _
0 0 o is 0 8
7044; Business and Professions Code).
OWNER El 1, as owner of the property, am exclusively contracting „2 o co 2 0.5 0
with licensed contractors to construct the project (Sec- MAIL -
tion 7044, Business and Professions Code).' ADDRESS2 Q'5 Q'H
ro 0 0 -!
CONSTRUCTION LENDING AGENCY CITY TEL. NO.
I.hereby affirm that there is a construction lending agency for �O 2 0'6 8 4
the performance of the work for which this.permit is issued CONTRACTOR D
(Sec. 3097, Civ. C.).
ADDRESS
Lender's Name
CITY TEL. NO.
Lender's Address
STATE LIC:
I 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 hereby author,ze•re resentatives of this County to enter
upon the above- ntio e property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date