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Home My Public Portal About11021 GREEN TREE LN_Mechanical__ WORKERS' COMPENSATION DECLARATION APPLICATION FOR PERMIT I hereby affirm that I have a certificate of consent to self insore`,ter a certificate of Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING or a certified copy thereof (Sec. 3800, Lab. C ) CE-818 0O � CE-818(REV. 10/81) IDcy rt c © Company COUNTY OF LOS ANGELES BUILDING ND SAFETY Certified copy is hereby furnished. Certified copy is filed with th county building inspec- FOR APPLICANT TO FILL IN BUILDING tion d partm nt. (PRINT OR TYPE ONLY) ADDRESS Date Appl ican LOCALITY NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FRO WORKERS' 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 UV permit is issued, I shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws. BOILER, BTU �j APPROVALS DATE I P TOR'S SIGN TURF Date Applicant / COMPRESSOR, BTU / 2t DDO (d 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 VALIDAT16N with comply with such provisions or this permit shall be deemed revoked. FURNACE: FAUGR V TY 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 my license is in full force and effect. CL 3' License Number 3g `-'a5— Lic. Class �� , `) I= Contract ate 7 I S O ❑ I am exemp under Sec. LU Plan check fee B.&P.C.for this reason' PERMIT ISSUING FEE S D Dare: ;22531 A Signature TOTAL FEE OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT # 0 0 0 0 0 8 I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and NAME , •) o 0 3 Q 5 0 Professions Code): ❑ I, as owner of the property, or my employees with ADDRESS ° ° 0.3 Q 5 0 c=i wages as their sole compensation,will do the work and the structure is not intended or offered for sale(Section CITY TEL. No. 0 7,2 5=g 5 7044, Business and Professions Code). OWNER ❑ I, as owner of the property, am exclusively contracting PrA with licensed contractors to construct the project (Sec- MAIL tion 7044, Business and Professions Code). ADDRESS CONSTRUCTION LENDING AGENCY CITY �� TEL. NO. p I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued CONTRACTOR JJP 4 (Sec. 3097, Civ. C.). ADDRESS 03 Lender's Name Lender's Address v CITY TEL. NO.Q- 3 16111 6Il1 I certifythat I have read this a on an ate that the STATE �� p LIC. _A0 pp LICENSE NO. O CLASS (.� O'� above information is correct. I-gr e to mply ith all County rdinances and State laws rela ng to Hui di construction, Ind reby a tri epresent tives o this ounty to enter ov - nti ed pr p rty fo ins on purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE n re of Appli nt or Agent Date -