Loading...
HomeMy Public PortalAbout11024 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 certifie py thereof (Sec. 3800, Lab. C ) 76A364C 0O� � ©0(9 3coCE-818(REV. 10/81) Policy No. Company COUNTY OF LOS ANGELESBUILDIN AND SAFETY Certified copy is hereby furnished. ertified copy is filed with the county building insp c- FOR APPLICANT TO FILL IN BUILDING tion de7portment.. ADDRESS (PRINT OR TYPE ONLY) Date �"Applican LOCALITY ; NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FRO RKERS' 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 (5100)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 so as to become subject to the Workers'Compensation Laws. BOILER, BTU APPROVALS DATE /TOR'S SIGNATOR Dare Applicant COMPRESSOR, BTU r O®D t® ROUGH NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL Exemption, you should become subject' to the Workers' —7/ Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VAL DATIO with comply with such provisions or this permit. shall be deemed revoked. FURNACE: FAU G V TY LICENSED CONTRACTORS DECLARATION FLOOR BTU 0 I hereby affirm that I am licensed under provisions of Chapter 9HEATER: SUSPENDED—UNIT— (commencing USPENDED UNIT WALL (commencing with Section 7000) of Division 3 of the Business � and Professions Code,and my license is in full force and effect. License Num er J Lic.Class —�©� J 0.7 0 Contract ate 0 F_ ❑ I am exemt under Sec. U Plan check fee B.&P.C. for this reason PERMIT ISSUING FEE $ Date- Signature Signature TOTAL FEE OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT ,2 5 4L 1 A I hereby affirm that I am exempt from the Contractor's License ► Law for the following reason (Section 7031.5, Business and NAME }t.0 0 4 R Professions Code): 1 .. J U ❑ I, as owner of the property, or my employees with ADDRESS o o o 3 Q 5 O 5 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 25-85 7044, Business and Professions Code). r ❑ 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.� 1 hereby affirm that there is a construction lending agency for . �� e , the performance of the work for which this permit is issued CONTRACT (Sec. 3097, Civ. C.). ADDRESS V.Sr T Lender's Name G ��� CITY 1 � TEL. NO. Lender's Address certif that I have read this a lic ion an state that the STATE p LIC. /+ �y C) y pp LICENSE NO. V CLASS l.►� O�l.1 ove information is correct. I agree t comply ith all County o inances nd ate laws rel o buildi g construction,, by a o i e eprese tativ s of thi County to enter It U or ntio ed p pert for in ec'on pur.oses. SEE REVERSE FOR EXPLANATORY LANGUAGE �r .'lAppli Ynt or Agent a e