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Home My Public Portal About11014 GREEN TREE LN_Mechanical__ WORKERS' COMPENSATION DECLARATION APPLICATION FOR PERMIT insurebor a certificate of Workers"Comtpensation Insurancee of consent to f or a certified co thereof (Sec. 3800, Lab. C.), �aA3a4c HEATING - VENTILATING - AIR CONDITIONING o0gca_Vy7—000s CE-818(REV. 10/81) Policy No. Company, Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDIN5 AND SAFETY Certified copy is filed with the county building ins pec- FOR APPLICANT TO FILL IN BUILDING tion department. (PRINT OR TYPE ONLY) ADDRESS Date��APPI ica LOCALITY NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FRO WORKERS' NEAREST COMPENSATION INSURANCE CROSS ST. GL (This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO. ROCESSED BY the permit is for one hundred dollars ($100)or less.) �� I certify that in the performance of the work for which this AIR HANDLING UNIT, CFM U b P C41 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 SIGN URE DateApplicant COMPRESSOR, BTU �o(� !/��/ lv 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 VALIDAT N with comply with such provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY 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 jmyy'license is in full force and effect. License Number 3a / a Lic. Class C —C2© ► V Contracto ate O ❑ I am exemp under Sec. Plan check fee B.&P.C. for this reason rE PERMIT ISSUING FEE $ � ;E Date: TOTAL FEE ;2 2 5 3.2 A Signature OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT # e:* e s a 8 I hereby affirm that I am exempt from the Contractor's License ► Law for the following reason (Section 7031.5, Business and NAME ( a.® 3(1 5 0 Professions Code): ❑ I, as owner of the property, or my employees.with ADDRESS ® ® ©.3 Q 5 0 wages as their sole compensation,will do the work'and the structure is not intended or offered for sale(Section CITY TELNO. .07,25-85 7044,.Business and Professions Code). OWNER r ❑ 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 �^ (�/1 li� i CONSTRUCTION LENDING AGENCY CITY TEL. NO. - I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued CONTRACTOR (Sec. 3097, Civ. C.). ADDRESS O Lender's Name CITY TEL. NO./'� r33106/1) Lender's Address (•/ STATE n LIC / ^O certify that I have read this application and st e hat the LICENSE NO. 3'' CLASS ove information is correct. I agree to m ly w h a County o inances and Sate la relating t buil ingco truction, utho r r entativ of t s Cr u y to enter a e- ti ed rop ty for i pecti pur oses. SEE REVERSE FOR EXPLANATORY LANGUAGE i Lure of AR . t or Agent Date