HomeMy Public PortalAbout10553 LYNROSE ST_Mechanical__ WORKERS'COMPENSATION DECLAR6TION
I hereby affirm that I have•a certificate of consent to Self APPLICATION' FOR PERMIT
insure, or a certificate of Workers'Compensation Insurance, 76a3�c HEATING - VENTILATINGI- AIR CONDITIONING
or a certified copy thereof(Sec. 3800, Lab. C.) CE-818(REV. 10/81)
Policy No. Company-
Certified.copy is hereby furnished.. COUNTY OF LOS ANGELESBUILDING AND SAFETY
❑ Certified.copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING
tion department. ADDRESS
(PRINT OR TYPE ONLY)
DateApplicant LOCALITY 1
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE.'OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE I CROSS ST. -
(This seetidn 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, ( n
I certify that in the performance of the work for which this
CFM
J `J
permit.is issued,I shall not employ any person inan nner BOILER,BTU•
so as:to become subject to the Worke Com Pon
Ion, ws. APPROVALS DATE INS CTOR'S SIGNATURE
Datey. Z li It- COMPRESSOR,'BTU G O O F ROUGH IA
NOTICE TO APPLICANT: P If, r niaking C rtificate of '' VENTILATION SYSTEM FINAL
Exemption, you should become subjec to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPO ATI VALIDA ON
with comply with such provisions or this ,permit shall be - -
deemed-revoked. FUR ACE; F RAVITY
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 t
and Professioris Code,andmy'license is in full force and effect.
�oL7/p/4 . C"moi G
License Number Lic:Class
Contractor ! Date V
_1 -_m exempt under Sec. LU
Plan check The CL
B.BP:C. for,this reason' PERMIT ISSUING FEE$ p Un
D to
Si natur' TOTAL FEE
g
i.
OWNER-BUILDER ggl.ARATION 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):
El I, 'as owner of the 'pioperty, or my employees with ADDRESS A��Toav
wages as their sole compensation,will do the work and CITY TEL.NO.
the structure'is not intended or offered for sale(Section 3307 is
7044, Business and Professions Code).
OWNER- 1 ITEM
El1, as owner of theproperty, am-exclusively contracting
with licensed contractors to construct the project (Sec- MAIL TOTAL 41 m j30
tion 7044, Business and Professions Code). ADDRESS
CONSTRUCTION LENDING AGENCY. CITY TEL NO. CHECK 41°00
I hereby affirm that there is a construction lending agency for CHANGE .00.the performance of the work for which this permit is issued CONTRACTOR Z ® " .
(Sec. 3097, Civ: C.).
ll pp
4 ADDRESS a6 LtU4NTV41Vi 4/1 / 7
Lender's Name q p t,� p +�
CITY TEL. NO, 7 399 f 1 AM 7 o L{
Lender's Address ' . t
I certify that I have read'this application and state-that the STATE - LIC.
• LICENSE NO. �`0�-9 � CLASS �-
above information is correct. I agree•to•comply with all County' j
ordinances'and'State laws relating to building construction,
a ereby authorize representatives..of this County to enter '
on the abov - ti nod roperty'for inspection purposes. ' 'I: SEE REVERSE FOR EXPLANATORY LANGUAGE
Sigriatur o pp icant or Agent Date ;