HomeMy Public PortalAbout9570 LAS TUNAS DR_Mechanical__ WORKERS' COMPENSATION DECLARATION APPLICATION FOR PERMIT
I hereby affirm'that I have a certificate of consent to self
Ingure, or a certlflcate 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 gs S
Date Applicant LOCALITY
NO TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST l�tJ
(This section need not be completed if the work Involved by ABSORPTION UNIT, BTU DISTRICT NO PROCESS BY
the permit is for one hundred dollars ($100)or less.) L O
I certify that In the performance of the work for which this AIR HANDLING UNIT, CFM v
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers'Compensate Laws BOILER, BTU ��} APPROVALS DATE INSPECTOR'S 5 ATURE
COMPRESSOR, BTU O0`� wL
7D OC ROUGH
Date/ pplIcan
NOTICE TO A PLICANT If, aft making this rer7ificatl 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 JL E� /OLJ
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 Professions Code, and my license is in full force and effect
License Number v /004? icLic Class�O 0 9 al V
Contractor/ Date 161,5D ► Q
# o o 0 1 0 0
Ia � 350 �
F-1 LU
I am exempt under Sec
Plan check fee U
H
B&P C for this reason Z
PERMIT ISSUING FEE Q —
Date
TOTAL
OTAL FEE
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 Code)
❑ I, as owner of the property, or my employees with ADDRESS
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 r r
❑ 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 7
CONSTRUCTION LENDING AGENCY CITY V ` TEL NO
I hereby affirm that there is a construction lending agency for Poo.the performance of the work for which this permit is issued CONTRACTOR
(Sec 3097, Civ C )
ADDRESS
Lender's Name
CITY 9 TEL NO
Lender's Address
STA E ^d 0918 LIC //�
I certify that I have read this application and state that the LICENSE NO -/ CLASS (i
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
,2yon the above entioned property for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
t
Signature of Applicant o Agent Date