HomeMy Public PortalAbout10733 LORA ST_Mechanical__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
4 herdby affirm that I have a certificate of consent to self
insure, or a certificate of Workers'Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
or o}Fertified copy thereof(Sec. 3800, Lab.C.) 76A364C
CE-818(REV. 10/81)
f 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 �7 7
tion department. ADDRESS 1 a 3 5
(PRINT OR TYPE ONLY)
Date Applicant LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEARESTh .
COMPENSATION INSURANCE CROSS ST.
(This section neod not be completed if the work involved by ABSORPTION UNIT,BTU DISTRICT NO PROCESSED BY
the permit is for one hundred dollars($1100)or less.) ,y t� (�,� —3
AIR HANDLING UNIT,CFM /.J � 7`--
1 certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner BOILER,BTU
so as to become subject to the Work C e Ion L Ws. APPROVALS DATE I PECTOR'S SIG yATURE
c` 7 COMPRESSOR, BTU 11d-1 dZrV (x j ROUGH L i
Dat Applicant
NOTICE TO APPLICANT: If, after making this Certificat of VENTILATION SYSTEM FINAL
Y
Exemption, you should become subject to the W kers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALID AT bN
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION d FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
(commencing with Section 7000) of Division 3 of the Business WALL
and Professions Code,and my license is in full force and effect. 9L
00
License Number Lic. Class ® V
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Contractor Date
ls-
❑ 1 am exempt under Sec.
Plan check fee 9L
N
B.BP.C. for this reason Date: PERMIT ISSUING FEE$
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Signature TOTAL 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
Prof ssions Code): -
I, as owner of the property, or my employees with ADDRESS 3 3 LQ
wages as their sole compensation,will do the work and CITYrL—Ve— TEL. NO.
the structure is not intended or offered for sale(Section
7044, Business and Professions Code).
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 CITY 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
(Sec. 3097, Civ. C.).
ADDRESS
Lender's Name
CITY TEL. NO.
Lender's Address
STATE LIC.
I 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 anclAtqte laws rela' g to building co truction,
and by th pr s t iVinsp
y to enter
up t a en d pert n purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Si nature of Applicant or Agentote