HomeMy Public PortalAbout10161 LOWER AZUSA RD_Mechanical__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
' 'I hereby. affirm that I have a certificate of consent to self ,
'insure, ora certificate of Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof (Sec. 3800, Lab. C.) 76A364C. ,
CE-818(REV. 10/81)
Pohc No.� �� ompony
Certified copy is hereby furnished. COUNTYOFLOS ANGELES BUILDING AND SAFETY
❑ Certified copy is filed.with the co t b ildin inspec- FOR APPLICANT TO FILL IN BUILDING /,r_
tion department ADDRESS I6
p (PRINT OR TYPE ONLY)
Dare r 6 Applicant LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CE IC E OF EXEMPTION FROM RKER ' NEAREST
OMPENSATION INSURA 1 E 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
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws. BOILER, BTU / 6,
APPROVALS DATE ' ECTOR'S SIGNATURE
0 Date Applicant COMPRESSOR, BTU ` e l wv 16 ROUGH
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 VAI IDA N
with comply with such provisions or This permit shall be
deemed revoked. FURNACE: FAU G VITY f'
LICENSED CONTRACTORS DECLARATION FLOOR BTU J Uo
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 m license is in full force and effect.
License Number "' 403 Lic. Class
Contrac A�l `� Date / o
❑ I am exempt under Sec. 1 LU
Plan check fee
B.&P.C.'for This reason
PERMIT ISSUING FEE $ 1j z
Date:
Tr S U
Signature OTAL 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
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).
OWNER
EJI, as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec- MAIL vV
tion 7044, Business and Professions Code). ADDRESS
CONSTRUCTION LENDING AGENCY CITY . Qf8�3 EL. NO. �J� ��o2B•itr�
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 /1 4-Al- TEL. NO. �
Lender's Address V`
STATE LIC. C�
I certify that I have read this application and state that the LICENSE NO. �� CLASS
above info ati is correct. I agree to comply with all County
ordinances a tote laws relating to building construction,
and ereby a h rize represen tives of this County to enter
upo he ab v - e Toned pr perty for irpe tion purposes. SEE REVERSE FOR EXPLANATORY.LANGUAGE
ig ureA !p i I or Agen / Dat -