HomeMy Public PortalAbout9646 LONGDEN AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
I hereby.off irm'that I have a certificate of consent to self
insure, or 8•'certif'lcate 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 COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is hereby furnished.
❑ 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 G 6t:_T
NO. TYPE OF APPLIANCE OR EQUIPMENT, FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST.
(This section need-not be completed If the work involved by ABSORPTION UNIT, BTU DISTRICT NO. PROCESSED 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 lA ao
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 15 TOR'S IGNATURE
DateApplicant., COMPRESSOR,BTU /7 c/Q� j ROUGH ._
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL i r
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 TY DD
LICENSED CONTRACTORS DECLARATION FLOOR BTU
1 herebyaffirm that I am.licensed under provisions of Chapter 9 SUSPENDED UNIT w
is P HEATER:
'(commencing with Section 7000)of Division 3 of the Business WALL y,
and Professions Code,•and my license is in full force and effect. 0.
License Number 6 fZ Lic.Class
Boo. V
0
I am exempt under Sec.
Plan check fee IL
N
BAP.C. for this reason' PERMIT ISSUING FEE$
Date: TOTAL FEE 5V ;2 3 4 9.2 A
Signature # a o e o a 8
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT ,1 -.13 (150
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and NAME , a a 1 3 Q 5 Q mu
Professions Code):
El 1, as owner of the property, or my employees with ADDRESS 4 1. 18=8 5
wages as their sole compensation,will do the work and CITY TEL. NO.
the structure is not intended or offered for sale(Section
7044, Business and Professions Code). v
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
CONSTRUCTION LENDING AGENCY CI TEL. NO.
1 1 hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued CONTRACTOR 0 ►
(Sec. 3097, Civ:C.). Old 61
ADDRESS
Lender's Name
CITY - TEL. N
Lender's Address A E LIC.
I certify that I have read this application and state that the LICENSE NO _3 CLASS 2-0
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
upon the above-mentioned property for inspection purposes. SEE REVERSE FOR-EXPLANATORY LANGUAGE
�'• Date
'Signature of Applicant•or,Agent