HomeMy Public PortalAbout9031 EMPEROR AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
I hereby affirm that I have a certificate of consent to self '
'Insure, or a certificate of Workers' Compensation Insurance, - - HEATING VENTILATING - AIR CONDITIONING
or a certified copy tkereof (Sec 3800, Lab C ) 76A364C
CE 818(REV 10/81) --
Polley No Company _ fT
2---Certified copy is hereby furnished COUNTY OF LOS ANGELES - BUILDING AND SAFETY
❑ Certified copy Is filed with the county building inspec- FOR APPLICANT TO FILL IN - BUILDING
tion department �/
Date f� / (PRINT OR TYPE ONLY) ADDRESS
Applicant�Nf���4�1�'/i7 LOCALITY /�
" 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 forgone hundred dollars ($100)or less ) !r�
I certify that In the performance of the work fo'r which this AIR HANDLING UNIT CFM G
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 INSPE 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 VA IDATIO
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 SUSPENDED—UNIT—
(commencing
USPENDED UNIT(commencing with Section 7000) of Division 3 of the Business HEATER WALL
and Professions Code,and my license Is in full force and effect
IL0
License Number Lic Class U
Cr
Contractor Date ;2 7 7 8 2 A 0
ElI am exempt under Sec' # e e o • • 8 W
Plan check fee _ H
8 &P C for this reason PERMIT ISSUING FEE $ I( ° ° 2 Q; Z
Date `
Signature TOTAL FEE
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT • e Q=
j hereby affirm that'l am exempt from the Contractor's License
Law for the following reason (Section 7031 5, Business and NAME PooQ +8 7
Professions Code)
❑ j, as owner of the property, or my employees with ADDRESS ���
r wages as their sole compensation,will do the work and
the structure Is not intended or offered for sale(Section CIT Ys�� k �(���G TEL NO
7044, Business and Professions Code) OWNER t Ile
❑ I, as owner of the property, am exclusively contracting
withlicensed contractors to construct the project (Sec- MAIL
tion 7044, Business and Professions Code) ADDRESS 7 8 Q 6,A
CONSTRUCTION LENDING AGENCY CITY r- "
I hereby affirm that there,is a construction lending agency for P�y ® # o • • • o 8
the performance of the work for which this permit Is issued CONTRACTOR
(Sec 3097, Civ C )
ADDRESS ° - 2(150
Lender's Name I
CITY TEL NO _ 5 _
Lender's Address °p° ° Q 'Q
STATE LIC 0 U J 1 -87
`8 7
I certify that I have read this application and state that the LICENSE NO CLASS - a - _
above information is correct I agree to comply with all County
ordinances and State jaws relating to building construction,
and hereby authorize representatives of this County to enter `
upo a ove-mention property for Inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
SI nature of Applicant or Agent Date -