HomeMy Public PortalAbout9630 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 certi.fi d copy thereof(Sec. 3800, L b. C.) 76A364C
p ,,P •� CE-818(REV. 10/81)
Policy NaL� mpany �`"s�� ��1�
❑ Certified copy is hereby furnished. '� �WfsS'1, COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING L
tion department. ADDRESS
(PRINT OR TYPE ONLY)
Date Applicant LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM ORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST.
(This section need not be completed If the work Involved by ABSORPTION UNIT, BTU DISTRICT NO. PROCE ev
the permit is for one hundred dollars($100)or less.)
AIR HANDLING UNIT,CFM
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner
so as to become'subject to the Workers'Compensation Laws. BOILER, BTU APPROVALS DATE INSPECTOR'S SIGNATURE
COMPRESSOR,BTU 9.0,00-6 f ROUGH
I Date Applicant f
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers' v
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU ///�11
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED—UNIT—
'(commencing
USPENDED UNIT GA .�/
'(commencing with Section 7000)of Division 3 of the Business WALL / T
and Professions Code,and Imy license is in full force and effect. CL
License Number:�1-1- 6 Lic. Class C��
0
Contractor, Date
❑ I am exempt under Sec.
Plan check fee CL
W
BAP.C. for this reason'
Date:
PERMIT ISSUING FEE$
'
Signature 'A . �. 1 TOTAL FEE
OWNEItBUILDEi DECLARATION PLAN CHECK APPLICANT 0 3 O 3 .8
1 hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and NAME
�
Professions Code): it „ a o 0 0.
❑ I, as owner of the property or my employees with ADDRESS
wages as their sole compensation,will do the work and 7 0 - 20.50
CITY TEL. NO.
the structure is not intended or offered for sale(Section � r,', r 2
7044, Business and Professions Code).
OWNER
❑ I, as owner of the property,am exclusively contracting �S �'� - wwtt Q J 1 1 —8 7
with licensed contractors to construct the project (Sec- MAIL
ADDRESS H,v i
tion 7044, Business and Professions Code). - •
CONSTRUCTION LENDING AGENCY CITY `G Ct'C� TEL. NO.
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued CONTRACTOR &irk/ V I — w D,
(Sec. 3097, Civ. C.).
ADDRESS • Ip 1j AJ G
Lender's Name ry
CITY TEL. NO.
Lender's Address
STATE LIC.
I certify that I have read this application and state that the LICENSE NO. ( CLASS ��ZO
above information is correct. I agree to comply with all County
ordinances and State laws relating to building construction,
and herelly authorize representatives of this County to enter
upon th bove-menti ned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature o Applicant or Agent Date