HomeMy Public PortalAbout8927 HERMOSA DR_Mechanical__ . .WORKERS'CO Mt PENSATION DECLARATION APPLICATION FOR PERMIT
I hereby rJffirm-tfibt 1 have arcerti{icate of consent to self
InSZ8,.or d'certificate of Workers' Compensation Insurance, 76A364C HEATING - VENTILATING - AIR CONDITIONING
r
or.D certified copy thereof'(Sec. 3800, Lab. C.)
r��/� !,t r ll CE-818(REV. 10/81)
Policy No.?nr�9,�7Companyished. s /—bLl•F''
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 n �
tion department. ) (PRINT OR TYPE ONLY) ADDRESS 7
Dote�-�iii.Applicant 4A9 LOCALITY r {
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. PROCFSSED ev
the permit Is for one hundred dollars ($100)or less.) /]y
I certify that in the performance of the work for which this AIR HANDLING UNIT, CFM V f7
permit is issued, I shall not employ any person in any manner Zz
so as to become subject to the Workers Compensation Laws. BOILER, BTU
L� 7� L, .n }�' APPROVALS DATE SPECT SIGNATURE
Date /-�S-Ab Applicant COM-PPRESSOR`BTU 2 06049'es U ROUGH
NOTICE TO APPLICANT: If, after making tl'a Certificate of VENTILATION SYSTEM FINALIAr
Exemption, you should become subject to the Workers' '
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATI N
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU_GR /' AIL, 10Y
LICENSED CONTRACTORS DECLARATION FLOOR ITV BTU V
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER SUSPENDED UNIT_
'(cam WALL men<ing with Section 7000) of Division 3 of the Business >_and Professions Code, and my license is in full force and effect. fL
0ZLicense Numbe,_Z y Lic.{.Class ✓ V
Contractor�i-1"'-r ."-Y�P 01114110
, LE
❑ 1 am exempt under Sec. W
Plan check fee H
B.BP.C. for this reason'
Dote:
PERMIT ISSUING FEE $ Q SlU Z
_
Signature TOTAL FEE Q c$
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT ;5 3 8 Q 7 A
I hereby affirm that I am exempt from the Contractor's License
Low for the following reason (Section 7031.5, Business and NAME ► # e a e e e 8
Professions Code):
❑ I, as owner of the property, or my employees with. ADDRESS I e e 7050
wages as their sole compensation, will do the work and
the structure is not intended or offered for sole(Section CITY TEL. NO. e e e 7 0.5 0 Li
7044, Business and Professions Code). 1
OWNER 6/1i ) -
Elp1. 15=86
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.Zg S
I hereby affirm that there is o construction lending agency for Poo.the performance of the work for which this permit is issued CONTRACTOR '
(Sec. 3097, Civ. C.). 7zi �
ADDRESSA -
Lender's Name 'T
CITYA .f TEL. NO.., g / _
Lenders Address L� r
STATE LIC. rl
I certify that I have read this application and state that the LICENSE NO. L2 7 S CLASS C
above information is correct. I agree to comply with all County '
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County.to enter _
upon th above-mentione,fJ property for ins ection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signo Nre of Applicant or Agent Dote r '