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Home My Public Portal About11011 GREEN TREE LN_Mechanical__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT I hereby affirm that I have a certificate of consent to self insure, 6r'a certificate of Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING or a certified cop thereof (Sec. 3800, Lab. C. 76A364C, OO ' �f 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 inspec- FOR APPLICANT TO FILL IN BUILDING tion de :IiApplicart4AUMSe� ADDRESS p (PRINT OR TYPE ONLY) Date LOCALITY NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM ARKE6 NEAREST COMPENSATION INSURANCE CROSS ST. ABSORPTION UNIT,"BTU " DISTRICT NO. PROCESSED 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 J U l/.✓f� permit is issued, I shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws. BOILER, BTU APPROVALS DATE INSP Tc SIGNATURE DateApplicant COMPRESSOR, BTU Do 0 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 VALIDATION with comply with such provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY LICENSED CONTRACTORS DECLARATION I FLOOR BTU RD. 0 D d (O 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 forces and effect: License Number Lic. Classgig ( , Contracto ate t7�7 ❑ I am exempt under Sec. LU Plan check fee X 2 5 3,8 A A. B.RP.C. for this reason Date: PERMIT ISSUING FEE $ 0 0 0 0 0 $ e Signature TOTAL FEE OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT ' o - 3 0,5 0 I hereby affirm that I am exempt from the Contractor's License 26:Law for the following reason (Section 7031.5, Business and NAME ° ° °.3 0.5 0 v Professions Code): ❑ I, as owner of the property, or my employees with ADDRESS Q 7.25a--8 5 wages as their solecompensation,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 with licensed contractors to construct the project (Sec- MAIL tion 7044, Business and Professions Code). ADDRESS , CONSTRUCTION LENDING AGENCY CITYTEL. NO. I hereby affirm that there is a construction lending agency for �� , the performance of the work for which this permit is issued CONTRAT O (Sec. 3097, Civ. C.). ADDRESS. © Lender's Name �C CITY TEL. NO.(f/ 33 b Lender's Address STATE LIC. I certify that I have read this applicat' n a state that the LICENSE NO. r�r� CLASS C D above information is correct. I a to omp with all County ordinances St laws rel ing to buil ing construction, ereby a h ize epres tativ s t s County to enter o entio ed pert for spection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE ignature of p icant or Agent Date