HomeMy Public PortalAbout9861 LONGDEN AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION APPLICATION F®R PERMIT C-r L, /i/�9
A;'I-hereB'�affirm*thas I.hose a certificate of consent to self
insure, or a certificate of Workers' Compensation Insurance, HEATING - VENTILATING - ABR CONDITIONING
" or a certified copy thereof (Sec. 3800, Lab. C.) CE818
36418(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 Q
tt depart m n (PRINT OR TYPE ONLY) ADDRESS _d
Date IAJ Applic _� NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY
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($100)or less.)
AIR HANDLING UNIT,CFM
I certify that in the performance of the work for which this t
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws. BOILER, BTU APPROVALS DATE CTOR'S SIGNATPRE
Date Applicant COMPRESSOR, BTU &II a ROUGH
L
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL �Z '
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VA'In AT6
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAUVITY p�
LICENSED CONTRACTORS DECLARATION FLOOR BTU �J
I hereby affirm that I am licensed under provisions of Chapter 9SUSPENDED UNIT
(commencing with Section 7000) of Division 3 of the Business HEATER: WALL
and Professions Code,and my license is in full force and effect.
r O
License Number I Lic. Class ® V
Contractor�
O
❑ I—
I
I am exempt under Sec. LU
Plan check fee0 8 9,5 A CL
B. &P.C. for this reason PERMIT ISSUING FEE$ # 0 0 0 0 0 8
Date: TOTAL FEE ter- 1 0 0 7 8 5 0
Signature
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT o 0 0 7 8,5 0 C6
1 hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and NAME I 1 1 -88
Professions Code):
❑ I, as owner of the property, or my employees with ADDRESS C,
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 I
❑ 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 W
CONSTRUCTION LENDING AGENCY CIfy_JJ—_hAPJrTEL. NO.
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued CONTRACTOR
(Sec. 3097, Civ. C.).
ADDRESS ;(
Lender's Name
CITYTEL. NO.
Lender's Address d
STATE LIC.
1 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 hW4y authorize representatives of this County to enter
u th ove ntioned operty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
f:m-A?_9
Signature of Applicant or Agent Date