HomeMy Public PortalAbout9408 GIDLEY ST_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
CE-81
or a certified copy thereof (Sec. 3800, Lab. C.) C
CE 818(REV. 10/81)
Policy No. Company
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. (PRINT OR TYPE ONLY) ADDRESS
-bate Applicant 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 NOPROCESSED 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
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 INSPECTOR'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 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
USPENDED UNIT WALL }
(commencing with Section 7000) of Division 3 of the Business a
and Professions Code,and my license is in full force and effect. O
V
License Number Lic. Class Poo- W
J
Contractor Date
I am exempt under Sec. IMO
B.&P.C. for this reason Plan check fee
PERMIT ISSUING FEE $ a
Date: �2
Signature TOTAL FEE u'
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License ,
Law for the following reason (Section 7031.5, Business and NAME
Professions Code):
❑ 1, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and CITY TEL. NO. a
the structure is not intended or offered for sale(Section
7044, Business and Professions Code). OWNER
❑ I, as owner of the property, am exclusively contracting MAIL .e • t
with licensed contractors to construct the project (Sec- ADDRESS ,
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY TEL. NO..
I hereby affirm that there is a construction lending agency for
(Sec. 3097, Civ. C
.).the performance the work for which this permit is issued
CONTRACTOR
'
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 agreee to comply with all County
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter
upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent J Date