HomeMy Public PortalAbout8925 HERMOSA DR_Mechanical__ 1NORKERS: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 "
❑ y "„ p y �JQ�r CE-818(REV. 10/81)
Polic Na. Com on lY/ G UAJ
Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
® Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING
tion department. ADDRESS -
t (PRINT OR TYPE ONLY)
P L�-Y,� q- �. LOCALITY
Date Applicant b,g, f
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE -
CERTIFICATE OF EXEMPTION FROM 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 fqr one hundred dollars ($100) or less.)
I certify that in the performance of the work for which this AIR HANDLING UNIT, CFM
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws. BOILER, BTU �t// /� /, APPROVALS DATE INS P LOA,'
Date /�` _rfo ((�$/ CO1ErO BTU rss� QtyT oU ROUGH - i
Applicon
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers' Of
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER p VALIDATION
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU GRAVITY / J
LICENSED CONTRACTORS DECLARATION FLOOR
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
pm�y/ 1'"20license is in full force and effect. d
License Number 2 // 8Xo Lic. Class 2D , O
./ u Tc �
Contractor IfM Ac. nut,, O O
H
❑ I am exempt under Sec. :23811,6A
W
Plan check fee d
B.&P.C. for this reasonI # e o e s o 8 Z
PERMIT ISSUING FEES
Date:
Signature - TOTAL FEE 11050 ,( e .- 70. 50
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT e - 7Q5060
I hereby affirm that I am exempt from the Contractor's License 101Law'for the following reason (Section 7031.5, Business and NAME 0 1. 15"86
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
ElI, as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec- MAIL O
tion 7044, Business and Professions Code). ADDRESS O
CONSTRUCTION LENDING AGENCY. CITY l TEL NO. Cg -6 y5/
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.). - -
ADDRESS E
_ Lender's Name _
CITY A TEL NO.
Lender's Address 122
STATE r/ • LIC.
I certify that I have read this application and state that the LICENSE NO. / CLASS G Q - -
above information is correct. I agree to comply with all County
ordinances and State laws relating to building construction, r
and hereby authorize representatives of this County to enter
upon the above-mentioned property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date