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Home My Public Portal About11003 GREEN TREE LN_Mechanical__ • w � WORKERS' COMPENSATION DECLARATION APPLICATION. FOR PERMIT I hereby affirm that I have a certificate of consent to self PERM- IT .or a certificates of Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING or a certified copy thereof (Sec. 3800, Lab. C.) s 76CE-818 00 -7-0003 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 ins pec- FOR APPLICANT TO FILL IN BUILDING 1 tion part ent. (PRINT OR TYPE ONLY) ADDRESS LOCALITY Date App lic NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FR WORKERS' NEAREST COMPENSATION INSURANCE CROSS ST. ABSORPTION UNIT, BTU - DISTRICT NO. ROCESSED 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 V ILI/ 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 IN CTOR•S SIGNATURE Dare Applicant ( COMPRESSOR, BTU ©w Cr ROUGH ) I NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL — / O Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VA"r%ATI N with comply with such provisions or this permit shall be deemed revoked. FURNACE: FAU GV TY to 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 License Number,:�2 ' Lic. Class u as Z22535A 1119 Contract ate 0 ❑ I am exem under Sec. # o,o o 0 0 8 � Plan check fee 9• 8.8P.C. for this reason PERMIT ISSUING FEE $ Q 1 ° ° 3 a 5 0 Date: TOTAL FEE ° ° °.3 0 5 0 Signature OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT 07,25-85 1 hereby affirm that f am exempt from The Contractor's License Low 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 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, am exclusively contracting MAIL 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 poll.the performance of the work for which this permit is issued CONT RACTO (Sec. 3097, Civ. C.). ADDRESS �fa� Lender's Name CITY TEL NO. Lender's Address STATE L1C. I*above tifthat I have read this app tion and state that the LICENSE NO. �p�s CLASS p'V ation is correct. I agr a toamply with all County nd State laws relay g to building construction, a ho ' e repr ntesfthis County to enter e tione p op rty r ins ection purposes. SEE REVERSE FOR EXPLANATORYLANGUAGE plic t or gent Date