HomeMy Public PortalAbout11010 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, HEATING - VENTILATING - AIR CONDITIONING
or a certified cop thereof.(Sec. 3800, Lab. C. 76A364C
00a9J 7- 000-:? CE-818(REV. 10/81)
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icy No. Company
Certified copy is.hereby furnished. COUNTY OF LOS ANGELES BUII.0114G AND SAFETY
Certified.copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING
tion d ypartent. (PRINT OR TYPE ONLY) ADDRESS
nnh LOCALITY
Date daC Applican NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FR ORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST.
ABSORPTION UNIT, BTU DISTRICT NO. PROCESS 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
d
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws. IBOILER, BTU APPROVALS DATE SP CTOR'S SIG ATURE
Date Applicant COMPRESSOR, BTU �j 01W IV 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 VALIDATI N
with comply with such provisions or This permit shall be
deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU CC)
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 m�+y''license is in full force and effect.
License Number �/ O'�Lic. Class C'-a� ► U
Contra or ate / � w
❑ I am exempt under Sec. LU
Plan check ee
B.&P.C. for this reason
Date: PERMIT ISSUING FEE $
TOTAL FEE
Signature -2253.7 A
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License , # o o o o o 8
Law for the following reason (Section 7031.5, Business and NAME
Professions Code):
I o- 3050
❑ I, as owner of the property, or my employees with ADDRESS
wages as their sole compensation, will do the work and o 0 o 3 0.5 0 5
the structure is not intended or offered for sale(Section CITY TEL. NO.
7044, Business and Professions Code). OWNER 0 7.2 5-8 5
❑ I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec- MAIL
tion 7044, Business and Professions Code). ADDRESS s� LLQ�� ,
CONSTRUCTION LENDING AGENCY CITY TEL. NO._�0
3//»
I hereby affirm that there is a construction lending agency for
the performance of the work for which,this permit is issued CONTRA TOR pop.(Sec. 3097,Civ. C.).
ADDRESS Q
Lender's Name
CITY TEL. NO. $► F,33 /
Lender's AddressSTATE �j Q^� la
I certify that I have read this app ion and state that the LICENSE NO. S p� (� p�� CLASS 'p2�
above information is correct. I agr e to omply with all County
ordinances and State laws r g to building construction,
ereby i repre ent ivies f this County to enter
o en Toned prop rty f r inspection 7puroses. SEE REVERSE FOR EXPLANATORY LANGUAGE
o� ej
Signatu of A 'licant or Agent