HomeMy Public PortalAbout11026 GREEN TREE LN_Mechanical__ WORKERS' COWPENSATIO' DECLARATION
I hereby f`irm that I have a certificate of consent to self -APPLICATION FORPERMIT
nbure; or a certificate of Workers' Csmpensation Insurance, 76A364C' HEATING - VENTILATING - AIR CONDITIONING d�
or a certified copy thereof(Sec. 38011; Lab. C.
Q 0 3 O�Q 3 ' CE-8181( EV. 10✓81) n _
Policy No. Company `
COUNTY OF LOS ANGELES" BUILDING AND SAFETY
Certified copy is hereby furnisltd.
�j Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING
j tion epart nt. //JJ�� (PRINT OR TYPE ONLY) ADDRESS e�
Data 2 Applican i k/� LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM ORKERS' NEAREST J
COMPENSATION INSURANCE CROSS SL t / ,G�
(This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO. PROCESS D BY
the permit is for one hundred dollars($100)or less.),
AIR HANDLING UNIT,CFM
1 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 INSP, TOR'S SIGNATURE
Date Applicant COMPRESSOR, BTU 'f' 0D (Q ^�� ROUGH J d
NOTICE 70 APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL
Exeinpti6n, you should become subject to the Workers' ~
Comjaensation provisions.of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDA"Jen N
With comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU 'G VITY
LICENSED CONTRACTORS DECLARATION. FLOOR BTU A
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.
_s
License Nher - ?11�kLic. Class e 0
Contractor �nderSec.
date 7 a ® 0
❑ 253,OA L
1 am ex
i' Plan check fee cT.
B.&P.C. for this reason � v � '.
PERMIT ISSUING FEE $ G3 �(� o 0 0 0 °
_ Date:
Signature TOTAL FEE o o30,50
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License 0003G50:03
Law for the following reason (Section 7031.5, Business and NAME O 1.25 -85
Professions Code):
❑ I, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and CITY TEL. NO.
the structure is not intended or offered for sale(Section
7044, Business and Professions Code). .
❑ OWNER
I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec- MAIL n
tion 7044, Business and Professions Code). ADDRESS $'�.ar fj�� �
At
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.). W1 ,714
ADDRESS �7Q3
Lender's Name ) /
CITY TEL. NO.Op'! 1 L
Lender's Address
STATE �—j (r - LIC. ,f9
4bovethat I have read this a plicati n and state that the LICENSE NO. 9 D �J CLASS C `
ormation is correct. Ia ree to c mply with all County
es and State laws rel ting to wilding construction,
repr tdtives f this County to enter
en ne pr perry f r inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
f Appl ant or Agent