HomeMy Public PortalAbout9904 LAS TUNAS DR_Mechanical__ WORKERS'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
CE-818(REV. 10/81)
Policy No. Company
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
ADDRESS
tion department. (PRINT OR TYPE ONLY)
Date Applicant LOCALITY
NO TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST.
D .
(This section need not be completed if the work involved by ABSORPTION UNIT, BTU STRICT NoPROCESSED BY
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
permit is issued, I shall not employ any perso�, an., mannerBOILER, BTU r* ""^"""�""—^�^+so as to become subject to the Workers';ornon;n / APPROVALS DATE N3PECTOR'S SIGNATURE
COMPRESSOR, BTU ROUGH
Date Applicart4.
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 GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU
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 >_
CL
and Professions Code,and my license is in full force and effect. 0
License Number '4411.Y2 Lic. Class f L' W
Contractor
"LL, Date
.. f k. - }
I am exempt under Sec. Q
Plan check fee oc
B.&P.C. for this reason 0
PERMIT ISSUING FEE $ CL
Date:
Signature TOTAL FEE LU
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
r
I hereby affirm that I am exempt from the Contractor's License ,
Law for the following reason (Section 7031.5, Business and NAME ♦ • • s s
Professions Code):
❑ I, as owner of the property, or my employees with ADDRESS o • ;
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- MAIL
tion 7044, Business and Professions Code). ADDRESS f �[ r► / fj
CONSTRUCTION LENDING AGENCY CITY IqZ �J Ti TEL.
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued CONTRACTOR ll ��
(Sec. 3097, Civ. C.). _
ADDRESS &(,:- 6, !lj ., (.c1'�r(, 1uU�%
Lender's Name
Lender's Address CITY (- /� 7�(,�� TE
STATE
I certify that I have read this application and state that the LICENSE NO. CLASS
above information is correct. I agree to comply with all County
ordinances and State laws relating to building construction,
andherqpy authfr' represgnt vgs of this County to enter
upon a ione pr e y for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Da