HomeMy Public PortalAbout11015 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 copy thereof (Sec. 3800, Lab. C ) , 76A364C
co 9,?Y7-ov0 -3 CE-818(REV. 10/81)
Policy No. Com✓pany
Certified copy is hereby furnished.. COUNTY OF LOS ANGELES BUILDING AND SAFETY
rtlfied copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING If
Tion eparT nT. (PRINT OR TYPE ONLY) ADDRESS
Date Applican LOCALITY �
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM ORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST.
(This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO. PROCESSED 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
permit is issued, I shall not employ any person in any manner BOILER, BTU
so as to become subject to the Workers'Compensation Lows. APPROVALS DATE INS TOR'S SIGNATURE
COMPRESSOR, BTU00 O Q ROUGH
Date Applicant 1 0 /
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: FAUGR VITY +
LICENSED CONTRACTORS DECLARATION FLOOR BTU 10-:!= 1® �—
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 I WALL
and Professions Code,
and my license is in full force and effect.
License Number 3 98a.� Lic. Class C J�D , U
Contracto "` ^' ate O
t—
❑ I am exempt/under Sec.
Plan check fee
B.BP.C. for this reason to
PERMIT ISSUING FEE $ b
Date: TOTAL FEE :2 2 5 3,9 A
Signature
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT # o o. o e o 8
I hereby affirm that I am exempt from the Contractor's License ,
Law for the following reason (Section 7031.5, Business and NAME I o - 30,50
Professions Code):
❑ I, as owner of the property, or my employees with ADDRESS o o o.3 0.5 0 V
wages as their sole compensation,will do the work and
the structure is not intended or offered for sale(Section CITY TEL. NO. 7,2 5—$5
7044, Business and Professions Code). Q
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 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 CONTRACTOA ,
(Sec. 3097, Civ. C.).
ADDRESS O� �tiy
Lender's Name
CITY �J TEL. NO. 183/6
Lender's Address
STATE -6, p LIC. n O
I certify that I have read this appl'cc,
tio and state that the LICENSE NO. �.J a CLASS (�
above information is correct. I a e t co ply with all County
okdinances and tat laws rel in9 t b ilding construction,
eby au o ' e eprese ative of his County to enter
o a -m nti ned erty or I sp ction p rrposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
o,��
S nature o ppli ni r A nt Date