HomeMy Public PortalAbout10539 LYNROSE ST_Mechanical__ WORKERS'COMPENSATION DECLARATION APPLICATIONFORFOR PERMIT 12/(5/ ! rl
,4.hereby�ffirm that I have a certificate of consent to self
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insure, ora certificate of Workers'Compensation Insurance, HEATING - VENTILATING -,AIR CONDITIONING
CE-81
or a certified copy thereof(Sec. 3800, Lab. C.) C
CE 818(REV. 10/81) ,
Policy No. Company
Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
F-1Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING
tion department. (PRINT OR TYPE ONLY) ADDRESS
Date Applicant LOCALITY s ��
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 for one hundred dollars(;100)or less.) AIR HANDLING UNIT,CFM
I certify that in the performance of the work for which this
c V
permit is issued, I shall not employ any person 'S SI
in a BOILER,anner BTU EC
so as to beC e s ject to the Workers' mpe i Laws; APPROVALS DATE IN ORG TORE
r COMPRESSOR, BTU '7�f V& ® ROUGH
Date Applicari
NOTICE TOAPPLICANT: If, after making Is CertifiIte of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALI IA
with comply with such provisions or this permit shall be
deemed.revoked. FURNACE: FAU GRAVITY
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 +a"2 Lic. Class G ® , V
/ 09
Contracto vA 'r*Date 0
❑ I am exempt under Sec.
Plan check fee
BAP.C. for this reason' ;2 9 8 Q O A z
Date: PERMIT ISSUING FEE$.
TOTAL FEE ## o o o.0 o 8
Signature I '
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT I o - 20,50
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 o a o 2 Q 5 O:C.5
wages as their sole compensation,will do the work and CITY TEL. NO.
the structure is not intended or offered for sale(Section 0607f-88
7044, Business and Professions Code). OWNER
❑ I, 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 '--G1 J TEL. NO.., �4
i hereby affirm that there is a construction lending agency for Pool
performance of the work for which this permit is issued CONTRACTOR
(Sec. 3097, Civ. C.). '
i ADDRESS �' �
Lender's Name
Q�� NO � js f�•IJa(
Lender's Address CITY TEL.
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 and StateIqws relating to building construction,
and here author .presentatives of this County to enter
up th ov a toned proper for inspe Aonr SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature ofpplicant or A 1 Dote