HomeMy Public PortalAbout9621 LOWER AZUSA RD_Mechanical__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
j"i Ate r a certificate of WorkersrlCompensat oificate of n Insurance,nt to l
or a certified copy thereof(Sec 3800, Lab C ) 76A364C HEATING - VENTILATING - AIR CONDITIONING
CE-818(REV 10/81)
Qty No Company
Certified copy is hereby furnished COUNTY OF LOS ANGELES BUILDING AND SAFETY
❑ Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING
tion department (PRINT OR TYPE ONLY) ADDRESS
Date Applicant LOCALITY `
NO TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST \
COMPENSATION INSURANCE CROSS ST
(This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NOr
PROCESSED BY
the permit is for one hundred dollars($100)or less)Icertify that in the performance of the work for which this AIR HANDLING UNIT,CFM �
Permit is issued, I shall not employ any person in any manner III
so as to become subject
VQto' the Workers'Compensation Laws BOILER,BTU APPROVALS DATE INSPECT S SIGNATURE
Date nhcont G COMPRESSOR, BTU ROUGH
NOTICE TO APPLICANT If, after making &s Certificate o VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers'
Compensation provisions of the Labar Code, you must forth- EVAPORATIVE COOLER VALIDATION
with comply with such provisions or this permit shall be
deemed revoked FURNACE FAUGRAVITY
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 d
O
License Number Lic Class ► V
OC
Contractor Date O
❑ I am exempt under Sec ' 9 4 4,5 A G
Plan check fee V H
B&P C for this reason PERMIT ISSUING FEE $ # • • •,• •,8 Z
Date 1' • •2 (15"0
�
Si nature TOTAL FEE
g �
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT 0.410 -20,5'05
I hereby affirm that I am exempt from the Contractor's License ► 3 04,22-8 8
Law for the following reason (Section 7031 5, Business and NAME �
Professions Code)
�I. 1, as owner of the property, or my employees with ADDRESS(7 0 W-E(` S
wages as their sole compensation,will do the work and
the structure Is not intended or offered for sale(Section CI (� TEL NO
7044, Business and Professions Code)
OWNER
❑ 1, as owner of the property, am exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code)
CONSTRUCTION LENDING AGENCY CITY TEL NO
I hereby affirm that there Is a construction lending agency for e
the performance of the work for which this permit is issued CONTRACTOR
(Sec 3097, Civ C )
ADDRESS
Lender's Name
CITY 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 j agree to comply with all County
ordinances and State laws relating to budding construction,
and hereby authorize representatives of this County to enter
upon the above-menti ne property for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
Si ature of App scant or Agent Date t