HomeMy Public PortalAbout6237 LOMA AVE_Mechanical__ WORKER6'COMPENSATION DECLARATION n P n U C n Y P O N FOR PERMIT
I hereby pffirrin that I have a certificate of consent to self
inure, o�aprtificate of Workers' Compensation Insurance, 7bA3e4c BEATING - VENTILATING - AIR CONDITIONING
orra certified copy thereof (Sec 3800, Lab C )
CE-818(REV 10/81)
Policy No Company
Certified copy Is hereby,furnished COUNTY OF LOS ANGELES BUILDING AND SAFETY
❑ Certified cSpy is filed with the county building inspec- FOR APPLICANT.TO FILL IN - BUILDING
tion department (PRINT OR TYPE ONLY) ADDRESS
Date Applicant LOCALITY /
NO TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE I CROSS ST
(This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO PROCESSEDY
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 d
permit is Issued, I shall not employ any person in any manner BOILER, BTU
so as to become subject to the,Workers Compensation Laws APPROVALS DATE ECTOR'S SIG AT
DateURE
COMPRESSOR, BTU Ov4 ROUGHof
Z-
� 7Applicant'
NOTICE TO APPLICANT If, afte making this Certific too . VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDA N
with comply with such provisions or this permit shall be
deemed revoked FURNACE FAU GRAVIT ,l
LICENSED CONTRACTORS DECLARATION FLOOR BTU O Dd
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 my license is in full force and effect
91116O
License Number Lic Class - V
Contractor Date O
# 3 z,� � 1Z A V
❑ I am exempt unde"r Sec i I,a iO Q 5 16
- Plan check fee
B 8P C for this reason
Date PERMIT ISSUING FEE $ a °,o ° 3 Q 5 0 5
"
Signature TOTAL FEE o527-87
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License �- D
Law for the following reason (Section 7031 5, Business and NAME ��l
Professions Code)
j, 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 offer6d for sale(Section
7044, Business and Professions Code) -` n Flo
/T j, as owner of the property, am exclusively contracting OWNER L
with licensed contractors to construct the project (Sec- MAIL
tion 7044, Business and Professions Cod �3 I.-OMA
ADDRESS 6
CONSTRUCTION LENDING AGENCY CITY '�� L C1' TEL NO
I hereby affirm that there is a construction lending agency for D
the performance of the work for which this permit Is issued CONTRACTOR
(Sec 3097, Civ C )
LendADDRESS Lender's Name A, ,
CITY- / TEL NO
Lender's Address
STATE LIC
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 jaws relating to building construction,
and hereby authorize representatives of this County to enter
upon he above-mentionedprprope ty for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
Signoture of Applicant or Agent Date