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HomeMy Public PortalAbout10167 LOWER AZUSA RD_Mechanical__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT �I �heTeby affirm that I have a certificate of consent to self insure, or a.certificate of Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING � or a certified copy thereof(Sec. 3800, Lab. C.) CE-818 CE 818(REV. 10/81) Policy No. , 093 Company Certified copy is hereby furnished. COUNTY OF'LOS ANGELES BUILDING AND SAFETY �r—❑ Certified copy is filed with the31K�_ FOR APPLICANT TO FILL IN BUILDINGtion department. (PRINTOR TYPE ONLY) ADDRESSDate r ApplicantLOCALITY n / NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LL CERT ICAT OF EXEMPTION FROM W KERS' NEAREST COMPENSATION INSURAN CROSS ST. ABSORPTION UNIT, BTU DISTRICT NO. PROCESSED BY (This section need not be completed if the work involved by _ the permit is for one hundred dollars ($100)or less.) r AIR HANDLING UNIT,CFM �l 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 a APPROVALS DATE P TOR'S SIGN�TURE Date Applicant COMPRESSOR, BTU �r�©a� 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 VALIDA I T OPN with comply with such provisions or this permit shall be deemed revoked. / FURNACE: FAU VITY i• -t J i LICENSED CONTRACTORS DECLARATION FLOOR BTU IVL (J V 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 forces and effect. d License Number Lic. Class L , u Contractor �IODate 1VAlf o ❑ I am exempt under Sec. Plan check fee B.BP.C. for this reason Date: PERMIT ISSUING FEE $ S7j - 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 ► . Professions Code): ❑ -I, as owner of the property, or my employees with ADDRESS wages as their sole compensation,will do the work and ' CITY TEL. NO. the structure is not intended or offered for sale(Section 7044, Business and Professions Code). J OWNER e ❑ I, as owner of the property, am exclusively contracting V 11fi•C� with licensed contractors to construct the project(Sec- MAIL tion 7044, Business and Professions Code). ADDRESS CONSTRUCTION LENDING AGENCY CITY ALO TEL. NO W I hereby affirm that there is a construction lending agency for V , the performance of the work for which this permit is issued CONTRACTOR (Sec. 3097, Civ. C.). ADDRESS �� - Lender's Name CITY TEL. NO. / lr 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 an S to laws relating to building construction, and here,4y au ize r presentatives.of this County.to enter upon ih bov ent' ed roperty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE 01 Sign u o ppi nt or A i Dote r -