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Home My Public Portal About11007 GREEN TREE LN_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, ,eAse4c HEATING - VENTILATING - AIR CONDITIONING or a certified copy thereof (Sec. 3800, Lab. C. /^ O ca 3 rl�GQ o (.� CE-818(REV. 10/81) Policy No. �ompany c•` Certified copy is hereby furmshe COUNTY OF LOS ANGELES' BUI IN AND SAFETY Certified copy is filed with the county building inspec- FOR APPLICANT-TO FILL IN BUILDING tion eparTm nt. ADDRESS IP- (PRINT OR TYPE ONLY) Date IP- AppIiccn 4 NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY CERTIFICATE OF EXEMPTION FROM RKE NEAREST COMPENSATION INSURANCE CROSS ST. as-e, (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.) !� AIR HANDLING UNIT, CFM (/� I certify that in the performance of the•v✓ork for which this u.^.1 permit is issued, I shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws. BOILER, BTU `7 APPROVALS DATE INS TOR'S SIGN TORE Date Applicant COMPRESSOR, BTU 7��00 © ® ROUGH NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL '"� ,1 Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATI with comply with such provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY LICENSED CONTRACTORS DECLARATION l FLOOR BTU 00 t� 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. License Num r Lic. Class � _ '�' Contract Date d'�� 0 ❑ �25.33A u I am exem under Sec. . Plan check fee LU B.BP.C. for this.reason # o o o ® 0 8 Date: N� PERMIT ISSUING FEE $ ® 10 Signature TOTAL FEE 1 © ®.3 Q 5 0 OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT o o ® 3 0 5 0 5 I hereby affirm that I am exempt from the Contractor's License Law for,the following reason (Section 7031.5, Business and NAME , ],2 5-$5 Professions Code): ❑ I, 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 ❑. 1, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec- MAIL tion 7044, Business and Professions Code). ADDRESS AV UAAI�& CONSTRUCTION LENDING AGENCY CITY "TEL. NO. �-i©� rj I hereby affirm that there is a construction lending agency for J 72 the performance of the work for which this permit is issued CONTRACTOR (Sec. 3097, Civ. C.). ADDRESS .2O3 Lender's Name ✓��-t L Lender's Address CITY TEL. NOel,?331 19 I certify that I have read this a lic.tion state that the STATE `� LIC. Y Pp LICENSE NO. �J �� CLASS C i' oR-Cl ig%nature bove information is correct. I agree to co ply it all County rdinances and State laws relati b ildin construction, by out or' a resent tive of s ounty to enter abo e e t' d pr erty or i p tion pur oses. SEE REVERSE FOR EXPLANATORY LANGUAGE ppl ant or Agent Date - -