HomeMy Public PortalAbout4905 PERSIMMON AVE_Mechanical__ (2) WORKERS'r-OMPENSATION DECLARATION �!L U I�-- APPLICATI6446IR PERMIT
I hereby affirm that I have a certificate of consent to self �
a certificate of Workers'Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
CE-818
,or a certified copy thereof(Sec. 3800, Lab. C.) I
CE 818(REV. 10/81)
Policy No. Company
Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
❑ Certified coy is filed with the county Pec- FOR APPLICANT TO FILVIN building ins BUILDING C
tion department. ADDRESS
(PRINT OR TYPE ONLY)
Date Applicant LOCALITY 4T'e
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST. Al ZL r
(This section need not be completed if the work involved by ABSORPTION UNIT,BTU DISTRICT NO. PROCESSED BY
the permit is for one hundred dollars($100)or less.) �G
AIR HANDLING UNIT,CFM
I certify that in the performance of the work for which this
permit is issued, I shall not employ any erson in.any manner BOILER,BTU
s0 as t0 beCOm subject to the Worke pen ti0 Laws. [,/ ^` APPROVALS DATE IN PECTOR'S SIGNVTURE
s COMPRESSOR, BTU �r " 1' V ROUGH
Date L pplicant
NOTICE TO APPLICANT: If, after a Ing this C rtificate ofVENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATI N
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU VITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU `O
I hereby affirm that I am licensed under provisions of Chapter 9HEATER: SUSPENDED UNIT r, ?y
'(commencing with Section 7000)of Division 3 of the Business WALL
and Professions Code,and my license is in full force and effect. 4
License Number L C Lic. Class ��" , U
L,�
Contractor IVL4-
_ Date
❑ I am exempt under Sec. V
Iii
Plan check fee
B.&P.C. for this reason' to
11:3 PERMIT ISSUING FEE$ � V` z
Date: TOTAL FEE z 613 8 A
Signature
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT # 0 0 0 0.0 8
1 hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and NAME 1 0 030.50
Professions Code):
I, as owner of the property,'or my employees with ADDRESS
El
wages as their sole compensation,will-do the work and CITY TEL. NO. o o.0 3 Q 5 0 czi
the structure is not intended or offered for sale(Section
7044, Business and Professions Code), OWNER1 219-86
El1, as owner of the property,am exclusively contracting MAIL v
with licensed contractors to construct the project (Sec- ADDRESS o I ni
Awv—
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY TekPQ G TEL. NO. «z
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued CONTRACTOR (�f JkW/�,
(Sec. 3097, Civ. C.').
ADDRESS Coo
Lender's Name
CITY % / TEL.
Lender's Address lrr
STATE t LIC.CSS —y G..✓1
I certify that I have read this application and state that the LICENSE NO.
above information is correct. I agree to comply with all County
ordinanc d State laws relating to building construction;
and her t rize r pre ntatives of this County to er)ter y
upon - one roperty for ir>s ection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Si nctur of ppiicant or Agent Date e