HomeMy Public PortalAbout5551 PERSIMMON AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
' I hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers'Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof(Sec. 3800, Lab. C.) 76A364C
CE-818(REV. 10/81) ,rte•
I Policy No. Company f
Certified copy is hereby furnished. COUNTY OF LOS ANGELES / o BUILDING AND SAFETY
r
Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING �.— M In / y
tion department.
I ADDRESS
(PRINT OR TYPE ONLY)
LOCALITY
Date Applicant I C
NO. TYPE OF APPLIANCE OR EQUIPMENT ' FEE NEAREST r
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE CROSS ST. Tp- INS D/4!e
This section need not be completed if the work involved b ABSORPTION UNIT, BTU DISTRICT NO. PROC PROCESSED BY
( P Y
the permit is for one hundred dollars($100)or less.) I r-
AIR HANDLING UNIT,CFM
I certify that in the performance of the work for which this I s-jd J
permit is issued, I shall not employ any person in any manner 1 BOILER,BTU
so as to become subject to the Workers'Compensation Laws. I APPROVALS DATE INSPECTOR'S SIGNATURE
COMPRESSOR, BTU ,0d ROUGH
Date AIDplicgeLabor
NOTICE TO APPLICANT: If, a ng this Certificate of VENTILATION SYSTEM FINAL
Exemption, you should be le
to the Workers'
Compensation provisions of Code, you must forth- EVAPORATIVE COOLER - VALIDATION
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION II FLOOR BTU
1 hereby affirm that I am licensed under provisions of Chapter 9 I HEATER: SUSPENDED UNIT
(commencing with Section 7000)of Division 3 of the Business 1111
and Professions Code,and
/m/yy license is in full force and effect. i Q
License Number T/S Lic. Class d •
Contractor A4 1114 Enl�-• Date »—�� I O
�❑ V
I am exempt under Sec. W
Plan check fee h
�
B.&P.C. for this reason � ,--. .' ��. a � g
PERMIT ISSUING FEE j v o
U o u,c o R
I Date: TOTAL FEE
Signature0O
OWNER-BUILDER DECLARATION PLA CHECK A ICANT
I hereby affirm that I am exempt from the Contractor's License , c
Law for the following reason (Section 7031.5, Business and NAM v J
Professions Code): i I, I (j•—r J
❑ I, as owner of the property, or my employees with ADD
wages as their sole compensation,will do the work and Y TEL. NO.
the structure is not intended or offered for sale(Section
7044, Business and Professions Code). ��J
OWNER C�O� 'EL,W
El 1, as owner of the property, am exclusively contracting I with licensed contractors to construct the project (Sec- I MAIL ���1 C
tion 7044, Business and Professions Code). ADDRESS m/
CONSTRUCTION LENDING AGENCYl
' CITY TEL. NO.
I hereby affirm that there is a construction lending agency for II
the performance of the work for which this permit is issued I CONTRACTOR M.4 m 1NGi16P_1W .
(Sec. 3097, Civ. C.).
ADDRESS ISV& L J
Lender's Name
CITY LD-
TE
nTEL. NO.
Lender's Address
I certify that I have read this application and state that the LICENSE NO.�I.S OS CLASS
above information is correct. I agree to comply with all County
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter
upon the above-mentionedprop rty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
ig tur of Applicant or Agent, Date