HomeMy Public PortalAbout5317 NOEL DR_Mechanical__ WORKERS COMPENSATION DECLARATION APPLICATION FOR PERMIT
_W:%I h reby affirm that I have a certificate of consent to self
"ertilictsfe of WoAers Compensation Insurance 76A364C HEATING VENTILATING AIR CONDITIONING
or a cerci d copy thereof(Sec 3800 Lab C)
CE 818(REV 10/81)
Policy No Company
Certified copy is hereby furnished COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with the county b Idin Inspec FOR APPLICANT TO FILL IN BUILDING .- `
tion dep`rtmept (PRINT OR TYPE ONLY) ADDRESS �J,� 1
Date ^- L�V Applicant 4 -_ - NO TYPE OF APPLIANCE OR EQUIPMENT FEE I LOCALITY e C
CERTIFICATE OF EXEMPTION FROM W S NEAREST
COMPENSATION INSURANCE CROSS ST
(This section need not be completed if the work involved by ABSORPTION UNIT BTU DISTRICT NO (/ PROCESSE Y
the permit is for one hundred dollars(:100)or less) AIR HANDLING UNIT CFM
1 certify that in the performance of the work for which this
permit Is Issued I shall not employ any person In any manner BOILER BTU
so as to become subject to the Workers Compensation Laws APPROVALS DATE INS OR S SIGNATURE
Date Applicant COMPRESSOR BTU 16 A AI00 m Od 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 VALIDAT16NF
with comply with such provisions or this permit shall be
deemed revoked / FURNACE FAU VITY
LICENSED CONTRACTORS DECLARATION r FLOOR BTU Q d
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER SUSPENDEDUNIT
(commencing with Section 7000)of Division 3 of the Business WALL
and Professions Code and m license is in full force and effect IL
IL
License Nu—,-. �� Lic Class ` ~2_ ► V
Contractor Date F
❑ I am exempt under d
Plan check fee 41 H 3 8 Z
B 8P C for this reason PERMIT ISSUING FEE; S
Date # • • • • •
Signature
TOTAL FEE 1 • •3 Q 5 0
OWNER BUILDER DECLARATION PLAN CHECK APPLICANT • • *3(150'
1 hereby affirm that I am exempt from the Contractor s License ,
Law for the following reason (Section 7031 5 Business and NAME 0 0 7±8 b
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)
OWNER s
❑ I as owner of the property am exclusively contracting
with licensed contractors to construct the project (Sec MAIL
ADDRESS
tion 7044 Business and Professions Code)
CONSTRUCTION LENDING AGENCY CITYP C f TEL NO
I hereby affirm that there is a construction lending agency for ` CY ,
the performance of the work for which this permit is issued CONTRACTOR
(Sec 3097 Civ C)
ADDRESS
Lender s Name r
CITY TEL NO q 3
Lender s Address STATE LIC
I certify that I have read this application and state that the LICENSE NO CLASS �ZQ
above Information is correct I agree to comply with all County
ordinances and State laws relating to building construction
a hereby horize representatives of this County to enter
the a ment ned property for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
` 3 ? -9;1-6-
Signature of App or Agent Date