HomeMy Public PortalAbout11006 GREEN TREE LN_Mechanical__ WORKERS' COMPENSATION DECLARATION APPLICATION FOR PERMIT
I hereby affifm that I have a certificate of consent to self
tnsufe, or a certificate of Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof (Sec. 3800, Lab. .) 76A364C
0OA03-2-0,9,03 `/J,., CE-818(REV. 10/81)
Policy No. ompany
Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDI G AND SAFETY
144
0ertified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING
_ct,on partm nt. (PRINT OR TYPE ONLY) ADDRESS
Date Applica LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM RKERS' NEAREST
COMPENSATION INSURANCE CROSS ST.
(This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO. PROCESSED Y
the permit is for one hundred dollars($100)or less.) 5, m-
AIR HANDLING UNIT, CFM' v 8
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 IECTOR'S SIGNATURE
COMPRESSOR, BTU I OK DD� l� ROUGH
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL i
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VAL DATI N
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU GRAy-ITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU 2f 0 1 19�,'o C�
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. 9L
License Numb r 3 01,T2Lic. Class G.�D , t,D
Contract Date
211121.91-18y 0
F-
❑ I am exem under Sec.
Plan check fee �-
tA
B.&P.C. for this reason
Date: �
PERMIT ISSUING FEE $ tO �. ;2253,6A
TOTAL FEE
Signature # o 0 0 0.0 8
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License ► ( o o.3 Q 5 0
Law for the following reason (Section 7031.5, Business and NAME
Professions Code): o 0 o 3 0.5 0 5
❑ I, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and 07,25-8 5
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 Gl
6SJ!_14z"111-1
with licensed contractors to construct the project (Sec- MAIL
tion 7044, Business and Professions Code). ADDRESS
CONSTRUCTION LENDING AGENCY CITYVInLrri/�-v�'� 0._ TEL. NO. 30�
I hereby affirm that there is a construction lending agency for /J/�,, l
the performance of the work for which this permit-is issued CONTRACT O G�-CSW` �'Q � ' .
(Sec. 3097, Civ. C.).
ADDRESS S;,
Lender's Name f
CITYr TEL. NO.?/
t� f
Lender's Address
STATE �f LIC.
I certify that I have read this applicati and state that the LICENSE NO. J pc CLASS 5 —AO
bove information is correct. I agree to mply ith all County
dinances and State laws relatin to uildin construction,
by out 'z present Ive f this ounty to enter
t
0 0 do ed pro rty o insp tion purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
`21
nature of .plic nt r Agent Date