HomeMy Public PortalAbout10157 LOWER AZUSA RD_Mechanical__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
J hereby of it-em'that I,have a certificate of consent to self
inure, or a'certificate of Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
or a certifie o th eof (Sec. 3800, Lob. CC.) 76A364C
l6 I � _" /J/ E �7if//V:r�. CE-818(REV. 10/81)
Pol' o. Company
Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
❑ Certified copy is filed with the count uil ing i pec- FOR APPLICANT TO FILL IN BUILDING ,/
ADDRESS /
ti n de ariment. (PRINT OR TYPE ONLY)
t' —
Date r Applicant LOCALITY Millrem-t
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
TIFI ATE OF EXEMPTION OM W ERS' NEAREST
COMPENSATION INSURANC CROSS ST.
ABSORPTION UNIT, BTU DISTRICT NO. PROCESSED BY
(This section, eed not be completed if the work involved 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 o s
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 PECTOR'S SIG-ATURE
Dare Applicant COMPRESSOR, BTU ROUGH 7 — ---.
NOTICE TO APPLICANT: If, after making this Certificate 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
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' Lic. Class
Contract �79( Date O
H
❑ I am exem t under Sec. tJ
Plan check fee W
H
B.&P.C. for this reason'
Date: %� �
PERMIT ISSUING FEE $
Signature
TOTAL FEE
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License oil.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). w�
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 1
CONSTRUCTION LENDING AGENCY CITYj�� 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.). .'t ;-} r- :Y E f,::; a CO
ADDRESS �"/ ...Ce i'�� -L;,. I'r•t ...�I r.:::'- �'-i
Lender's Name CITY TEL.!_ / NO.
3> a 1
tl� (ter r
Lender's Address i• F 3 btu
STATE LIC. i;4
I certify that I have read This application and state that the LICENSE NO. > CLASS �v
above information is correct. I agree to comply with all County t
ordinances d tate I ws relating to building construction; r
f�r>a
and h by t rize presentatives of this County to enter :T!" �� (
upon h ob v e ned pro erty for inspect' n purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
m { GWS II t' +
S' ure of App cant or Age t Dat ILY1 141 t_•i �t7 p•r!