HomeMy Public PortalAbout10165 LOWER AZUSA RD_Mechanical__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
I•hgreby affirm that I have a certificate of consent to self
insure, or a certificate of Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
or a certifie opy thereof (Sec. 3800, Lab. C.) 76A364C
D�� S'TA-TT- � CE-818(REV. 10/81)
Policy No. Company �
Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
❑ Certified copy is filed with the co t b Id inspec' FOR APPLICANT TO FILL IN BUILDING
tion department. (PRINT OR TYPE ONLY) ADDRESS
Date / Applicant LOCALITY j 1
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTI KATE OF EXEMPTION FROM RKERS' NEAREST
COMPENSATION INSURANC 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
1 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 /� APPROVALS DATE I OR'S SIGNATURE
COMPRESSOR; BTU 00e> ROUGH
Date Applicant J
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 VALIDATI
ffid
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU GRAVI Y
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 Q� ) Lic. Class
y�"'�(J` r Z 0
Contracto Date
N
E:1I am exemp under Sec. V
Plan check fee a.
B.&P.C. for this reason
PERMIT ISSUING FEE $ .�
Dater TOTAL FEE
Signature
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that.I am exempt from the Contractor's License poll
for the following reason (Section 7031.5, Business and NAME
Professions Code):
ElI, 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 d /
❑ 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 0 L. NO(.FY�
I hereby affirm that there is a construction lending agency for `V ,
the performance of the work for which this permit is issued CONTRACTOR- 1
(Sec. 3097, Civ. C.).
ADDRESS
Lender's Name
CITYTEL. NO.� y�3
Lender's Address
STATE LIC. As
I certify that I have read this application and state that the LICENSE NO. CLASS ���f✓
above information is correct. I agree to comply with all County
ordinances a St to laws relating to building construction,
and,here y ut ze epresentatives of this County to enter
upon th bo e en Toned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE ,
l � t�
Signa r p is or Ag nt