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HomeMy Public PortalAbout11025 GREEN TREE LN_Mechanical__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT I here�;,y affirm that I have a certificate of consent to self 1 i6sure, or a certificate of Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING or a cert' i o it Sec. 3800, Lab. C ) 76A364C 0P` 2-OO©3 r CE-818(REV. 10/81) Policy No.—CompanyI G -L Certified copy is hereby furnished. COUNTY OF LOS ANGELES B L G D SAFETY Pol Xertified copy Js filed.with the county building insp FOR APPLICANT TO FILL IN BUILDING -1ction portTent' (PRINT OR TYPE ONLY) ADDRESS Date Applica. LOCALITYSI / l NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FRO ORKER ' NEAREST COMPENSATION INSURA E CROSS ST. (This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO. PROCESSED B 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 / EX permit is issued, I shall not employ any person in any manner J• (J(J so as to become subject to the Workers'Compensation Laws. BOILER, BTU T R' 1 APPROVALS DATE INSPECSIGNATURE ` Date Applicant COMPRESSOR, BTU Z 00 Q 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 AVITY �1 ,q LICENSED CONTRACTORS DECLARATION ( FLOOR eru V U 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. License Number Lic. Class -. , 2 5 IL 2 X V Contract r ate 0,0 0 0 0 8• ❑ I am exemp under Sec. LU Plan check fee IL N B.&P.C. for this reason PERMIT ISSUING FEE Signature S ° 0 3 Q 5 0 Date: e TOTAL FEE ° ° ° 3 Q 5 0.6. ' OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT 0 7,25-85 I hereby affirm that I am exempt from the Contractor's License , Law for the following reason (Section 7031.5, Business and NAME Professions Code): ❑ I, as owner of the property, or my employees with ADDRESS wages as their sole compensation,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- MAIL2L4 Z,16afdj tion 7044, Business and Professions Code). ADDRESS CONSTRUCTION LENDING AGENCYCITY J. TEL. NO.3 G) I hereby affirm that there is a construction lending agency for , the performance of the work for which this permit is issued CONTRA/CT e c . (Sec. 3097, Civ. C.). ADDRESS P Lender's Name CITY TEL. N.O Lender's Address c ertify that I have read this application nd state that the STATE LIC: y pp LICENSE NO. p CLASS — information is correct. I agree to com ly with all County ances and t e I s relatin bui ing construction, by auth iz ep sentat ves f t isCounty to enter ove- n oned rope ty f r in pe tionp rposes. SEE REVERSE FOR EXPLANATORY LANGUAGE V1 All re Applicant r Agent