HomeMy Public PortalAbout9064 OLIVE ST_Mechanical__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
I hereby affirm that I have a certificate of consent to self '
insure, &1a certificate of Workers'Compensation.Insurance, HEATING - VENTILATING -'AIR CONDITIONING
or c t" ied copy thereof(Sec. 3800, L C.)• CE-818 .
y —� p y CE-818(REV. 10/81)
c Com an COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is hereby furnished.'
Certified copy is filed with the county b ildin FOR APPLICANT TO FILL IN BUILDING OFx
G�]�A ion er fled ctment. (PRINT OR TYPE ONLY) ADDRESS t c°e
�� Applicant LOCALITY
A
pp NO. TYPE OF APPLIANCE OR EQUIPMENT FEE p
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST I
COMPENSATION INSURANCE CROSS ST.
(This section need riot be completed if the work involved by ABSORPTION UNIT,BTU DISTRICT NO. / PROCESSED BY
the permit Is for,one hundred dollars($100)or less.) AIR HANDLING UNIT,CFMv 1C
I certify that in the performance of the work for which this (. V
permit is.issued, I shall not employ any person in any manner
so as to become subject-to:the Workers'Compensation Laws. BOILER, BTU APPROVALS DATE INS CTOR' SIGNATURE
i COMPRESSOR,BTU 3 L OO O ROUGH
Date. Applicant.
NOTICE TO APPLICANT: If, after making this 'Certificate of VENTILATION SYSTEM FINAL
Exemption, you should .become subject to. the Workers'
Compensation provisions of the Labor Code, you must forth-
EVAPORATIVE COOLER VALIDATION
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU GRA ITY
LICENSED CONTRACTORS,DECLARATION FLOOR BTU `Z
I hereby affirm-that I am licensed under provisions of.Chapter 9 HEATER: SUSPENDED UNIT
'(commencing with Section 7000)of Division.3 of the Business - WALL
and Professions Code,and my license is In ull o^r�e and effect.
t � O
License Number •� Lic.-Class- ` � ► L)
+yDateU �
Contractor6oxN �
❑ I am exempt under Sec. ... ' O 2 b 0 A Au
Plan check fee
B.&P.C. for this reason'
PERMIT ISSUING FEE$ # e'0 0,0.0 8
• .Dare:
Signature TOTAL FEE ;I ° 3 Q 5.0
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am.exempt from the Contractor's License ► o o.,0 3-0,5 O
Law for the following reason (Section 7031.5, Business-and NAME
Professions Code): 07.
22 +88
❑ 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 ®A t /��le- /
❑ I, as owner of the property, am exclusively contracting �
with licensed contractors to construct the project(Sec- MAIL �®
tion 7044, Business and Professions Code). ADDRESS Q pi /�1�
CONSTRUCTION LENDING AGENCY CITY TEL. N
I hereby affirm that there is a construction lending agency for KS
the performance of the work.for which this permit is issued CONTRACTOR
(Sec. 3097, Civ. C.).
ADDRESS � ? A ��/C/t N'e-Lenders Name y
1 CITY
Lender's Address STATELIC.
I certify,that I have read this application and state that the LICENSE NO. ® CLASS XIC.1v
above information is correct. I agree to comply with all County
ordinances and State laws relating to building construction,
and hereby authorize-repres of this County to enter
upog,d9laboyp1m.entioned pr .perty r inspection p o s, SEE REVERSE FOR EXPLANATORY LANGUAGE
-2 -V
Signature of Applicant or Agent Date.
). It