HomeMy Public PortalAbout10159 LYNROSE ST_Mechanical__ WORKERS'COMPENSATION DECLARATION APF I��CA I1 P O N FOR PER 8 T '
I hereby.raffiTrn that 'I have,a certificate of consent to self
insure, or a certificate of Workers'Compensation Insurance, 76A364C 4 _ HEATING VENTILATING - AIR CONDITIONING
a certified copy thereof (Sec 3800, Lab C )
• �, �/� CE-818(REV 10/81)'
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Certified-copy is hereby furnished COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with the county building mspec- FOR APPLICANT TO FILL IN BUILDING
tion department ADDRESS I O S�
(PRINT OR TYPE ONLY;
Date�"�e ��' Appli l � •C3 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 NO PROCESSED B
the permit Is fer onehundred dollars ($100)or less.)
AIR HANDLING UNIT, CFM
I certifythat 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 BATE IN CTOR'S SIGNAT RE
COMPRESSOR, BTU �y�• Oa ROUGH
Date Applicant _ _ -
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 N
with comply with such provisions or this permit shall be
deemed revoked (1 FURNACE FAU GggyyITYV
LICENSED CONTRACTORS DECLARATION l FLOOR BTU �C Dv
I hereby affirm that am liHEATER censed under provisions of Chapter 9 SUSPENDED U" NIT
(commenting with Seciion'7000) of Division 3 of the Business WALL
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and Professions Code,and my license Is in full force and effect O
License Number �Z }IZ: Lic Class, U
COntra/1trJA4= Gk�C � Date �•ZCm�Q��
a -
I am exempt under Sec ui
Plan check fee - a
B 8P C for this reason - -
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PERMIT ISSUING FEE $
Date • � �2553•'A'
Sig - _ TOTAL FEE
.�� #,o,o,• 0 0 8
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that Iam,pxempt from the Contractor's License
Law for the following reason (Section 7031 5, Business and NAME ( o 0 3 a'5 Q
Professions Code)
• ❑ I, as owner of the property, or my employees with ADDRESS ti - ,o o,0 7J 0,5 0=v
wages-as their sole compensation,will do the work and CITY TEL NO ,71 2 6_855.
the structure is not intended or offered for sale(Section - 0
7044, Business and Professions Code)
Elry
I, as owner of the property, am exclusely'conirachOWNER
ng _
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with licensed contractors to construct the project (Sec- MAIL -
hon 7044, Business and Professions Code) ' ADDRESSIO •• _
CONSTRUCTION LENDING AGENCY CI -TEL NO
I heia-
reby affirm that there is a construction lending agency for
T
the performance of the work for which this permit Is issued CONTRACTOR _ �
(Sec 3097, Civ C
�C• ` - = -
Lender's Name ADDRESS2, J 04N
�.-+ • 5
CI TEL NO /
Lender's Address
STAT /7 LIC
I certify that I have read this 8— lication and state that the LICENSE NO •�2 -I V CLASS - • -
above information is correct I agree to comply with all County
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter
uponthe above-m n property for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE, '
Signature of Applicant _r A nt