HomeMy Public PortalAbout9826 LEMON AVE_Mechanical__ -WORKERS' COMPENSATION DECLARATION APPLICATION FOR• PERMIT
I,h(#reby afttrm that I have a certificate of consent to self
,dnsure,'at 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
tion department (PRINT OR TYPE ONLY) ADDRESS,
Date Applicant LOCALITY „
k Pel
CERTIFICATE OF EXEMPTION FROM WORKERS' NO TYPE OF APPLIANCE OR EQUIPMENT FEE NEAREST
COMPENSATION INSURANCE CROSS S
(This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO PROCESSED
the permit is for one hundred dollars (;100)or less.)
. AIR HANDLING UNIT, CFM
I certify that in the performance of the'work for which this _
permit Is issued,.)shall not employ any person in any manner
so as to becom s bl ct to the Workers'Com nsation La BOILER, BTU APPROVALS DATE If ECT 'S SIG ATURE
Date/ Applicant COMPRESSOR, BTU 1-1 y _ ROUGH S /
_- NOTI E TO PPLICANT If, after ma ing this Certifica e of VENTILATION SYSTEM FINAL
'`,Exemption, you should, become subject to the'Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER T VALIDATI N
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"
and Profession's Code, and my license is in full force and effect
License Number Lic Class V
Contractor Date 3 8 2 3 A
I am•exempt under Sec VW
Plan check fee n.
B&P C for this reason # o o o 0 lo 8 N.o - 2(150
DateZ
TOTAL FEE
PERMIT ISSUING FEES I
Signature M -
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT - - e o o20.505
I hereby affirm that I am exempt from the Contractor's License , Q 1. 14-86
Law for the following reason (Section 7031 5, Business and NAME
rPrrooffeessions Code) /
L5 I j, as owner of the property, or my employees with ADDRESS
wages-as their sole compensation,will do the work and
thstructure is not intended oi�offered for sale(Section CITY )TEL NO
7044, Business and Professions Code) `
❑ OWNER
I, as owner of the property, am exclusively contracting y
with licensed contractors to construct the project (Sec- MAIL `S .tion 7044, Business and Professions Code)
CONSTRUCTION LENDING AGENCY CITY "` TEL'NO`
I hereby affirm that there is a construction lending agency for CY
the performance of-the,work for which this permit is issued CONTRACTOR-
(Sec
ONTRACTOR(Sec 3097, Civ C )' -
- ADDRESS
Lender's Name
CITY . , TEL NO ,
Lender's Address - '
STATE LIC
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,
and hereby authorize.representatives of this County to enter
up the ab e-mentioned prop rty for in ection ur s s' SEE REVERSE FOR EXPLANATORY LANGUAGE
;
Si nature of Applicant or Agent /Date -