HomeMy Public PortalAbout9025 HERMOSA DR_Mechanical__ WORKERS'COMPENSATION DECLARATION APPLICATION
PPLIC A TION COO PERMIT
I hereby affirm that I have o certificate of consent to self- M /'1 1Y r Il PERMIT
insure, or acertificate of Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
or a certified 76AS64C copy thereof (Sec. 3800, Lab. C.) -
• CE -818(REV.'10�81) - —Policy No. Company
Certified copyis hereby furnished. COUNTY OF LOS ANGELES' BUILDING AND SAFETY
.
❑ Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING G�/)7� �r fj Q
tion department. (PRINT OR TYPE ONLY) ADDRESS ,�/+e.oL /]
Date Applicant _ LOCALITY /
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 pISTRIQ NO. PROCESSED BY
the'permit,is for one hundred dollars($100)or less.)
AIR HANDLING UNIT,LFM V O �
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 'INSPECTOR'S SIGNATURE
Dote L:� &_Applico n COMPRESSOR, BTU ROUGH
NOTICE ATO PPMCCCIIII PLICANT: If, 'after mating this Certificate of / VENTILATION SYSTEM FINAL
Exemption, you should. becomesubject to the Workers' -
Compensotlon provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALI AT
with comply with such provisions or this,permit shall"be "' ` - - - — - "-
deemed revoked FURNACE: -LAU R T i
LICENSED CONTRACTORS DECLARATION FLOOR BTU -
<-1 hereby off irm,ffici am-licensedunder,provision9gf.Chapter 9 - - "'HEATER'. -SUSPENDED UNIT__,
'(commencing with Section 7000) of Division 3 of the Business WALL
and Professions Code,and my
lliicense•s infull force and and eefect:
License Numbe / iLit ClassrnL
► V
n/ K
Contrador� [j/p!'ffr/ O
/ G
I am exempt under Sec.
Plan check fee — d
BAP.C. {or this reason- PERMIT ISSUING FEES - Z
Date:
.Signature - - TOTAL FEE _ Qa
OWNER-BUILDER DECLARATION' PLAN CHECK APPLICANT'.
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and NAME
Professions Cade):
❑ . _
I, as owner of the property, or my employees with ADDRESSr.—
wages as their sole compensation,will do the work and - Ai'u'I •T
the structure is not intended or offered for sale (Section CITY TEL. NO. _ ;-�•(_I
OWNER S_I
7044, Business and Professions Code). (� .
I, as owner of the properly, am exclusively contracting _ 1 ITEI'�:�
❑
with licensed contractors to construct the project (Sec- MAIL /��ql _ A ,r'
L
tion 7044, Business and Professions Code). ' ADDRESS d« TO -37 - 00
CONSTRUCTION LENDING AGENCY Cli TEL. No. i1i
1 hereby affirm that there is a construction lending agency,for i'NGL'�' Y -
the performance of the work for which this permit is issued CONTRACT RU-Ma , (, j- •i;1]
(Sec 3097, Civ. C:). NAFGE
ADDRESS: . . _ _
Lender's Name � r _
CITY TEL. NO. . s51.
Lender's Address
STA E LIC. _ ,lj 1' 'H1 t7
1 certify that I have read this application and state that the LICENSE N CLASS
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
Pon thea ve-mentioned property for inspection purposes. SEE REVERSE.,FOR EXPLANATORY LANGUAGE _
Sign ,re of Appl am en Dote