HomeMy Public PortalAbout10144 GREEN ST_Mechanical__ &ORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
I hereby affirm that I have a certificate of consent to self
Insurerr��or o per�Flcate of Workers' Compensation Insurance, 7&4-96.4C HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof(Sec. 3800, Lab. C.) CE-818(REV. 10/81)
No. Company
Certified copy Is hereby furnished.
BUILDING A
Policy COUNTY OF LOS ANGELESND S FETY
❑ Certlfied copy Is filed with the county building-Irspec- FOR APPLICANT TO FILL IN BUILDING
Hon department. ADDRESS(PRINT OR TYPE ONLY)
APP LOCALITY
Date Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE r
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST'
(This sectlon need not be completed If the work Involved by ABSORPTION UNIT, BTU Darr No. PROCEyM By ^
the permit is for one hundred dollars (;100)or less.)
A1R HANDLING UNIT, CFM
I certify that In the performance of the work for which this s
permit Is Issued, I shall not employ any p�O m enwn In any manner
so as to become subject to the Workers pensotion Laws. BOILER, BTU APPROVALS DATE NSPL`CTOfYS SIGNATURE
Date Amllcanf- COMPRESSOR, BTU ROUG41
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL x"
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAP 4ZATIVE COOLER VALIDATION
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby ofNrrrr that I a?n licensed under provisions of Chapter 9 HEATER: SUSPE _UNIT
'(commencing with Section 7000) of Division 3 of the Business WALL
and Professions Code,and my license Is In full force aril effect. d
O
License Number Llc. Clan , V
OC
Contractor Date 0
❑ I am exempt under Sec. sY
Plan check fee - tL
B.BP.C. for this reason y
PERMIT ISSUING FEE $ Z
Date: TOTAL EE p Q
Signature
OWNER-BUILDER DECLARATION PLAN CH APPLICANT
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and NAME
Professfom Code):
I, as owner of the property, or my employees with ADDRESSIV (7 8 5 4 1 A
g
waes as their sole compensation,will do the work and CITY TEL NO �{Y•
the structure Is not Intended or offered for sale(Secilorr 7 .4.0 o-0 0 0 8
7044, Bustn&p and Professions Code).
C7WtJER
El1, as owner of the property, am exclusively contracting 2'0'0 Z Q 5 0
with licensed contractors to construct the project (Sec- MAIL
tion 7044, Business and Professions Code). ADDRESS °,° ° 2 Q 5 0 H'
CONSTRUCTION LENDING AGENCY CITY TEL NO,
1223-82
I hereby affirm that there Is a construction lending agency for ,
the performance of the work for which this permit Is Issued CONTRACTOR
(Sec. 3097, CIv. C.}.
• ADDRESS-
Lenders Name
(7Tf TEL NO.
Lenders Address
STATE uc
I certify that I have read this application and state that the LICENSE NO. CLASS
above Information U correct. I agree to comply with all County
ordinances and State laws relating to building constructlon,
QrLd hereby authorize representatives of this County to enter
u n thea v menti h property for Inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
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tura of Appllcant or Agent Data -