HomeMy Public PortalAbout6258 PRIMROSE 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) ,
Policy No. Company I
Certified copy is hereby furnished. COUNTY OF'LOS ANGELES ' BUILDING AND SAFETY
.
Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING
tion department. I ADDRESS
(PRINT OR TYPE ONLY) •
Date Applicant IACALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE NEAREST
COMPENSATION INSURANCE CROSS ST. ,
(This section need not be completed if the work involved by ABSORPTION.UNIT,BTU DISTRICT NO. PROCESSE BY r
the permit'is-for one hundred dollars($100)or less.) AIR HANDLING UNITCFM -� f�
I certify that in the performance of the work for which this j, --00
( permit is issued,.l'shall not employ any person in any manner BOILERBTU
so as to become slubject to the Workers'Com ,Compensation Laws. APPROVALS DATE INSPECTOR'S SIGNATURE
Ddte_"' - pylic C COMPRESSOR)BTU ROUGH
NO CE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL
/// Exemption, you should become subject to the Workers'
' Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION
with Comply with such provisions or this permit shall be-
deemed revoked. FURNACE: FAU A Y'
•LICENSEDCONTRACTORS DECLARATION FLOOR- B7U �— D
I hereby affirm,that I am licensed under provisions of Chapter 9SUSPENDED UNIT '
,'(commencing with Section 7000)of Division 3 of the Business HEATER; WALL
t and Professions Code,and my license is in full,force and effect.
License Nu}nbe - Z4/Z-ILI . Class `' U
Co' Dafe ,i3 P,/ UUO
' I am exempt under Sec.
:Plan check fee H
B.&P.C. for this reason PERMIT ISSUING FEE'$ D �`C� Z
Date:
Signature TOTAL FEE C0
-OWNER-BUILDER DECLARATION' PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 703.1.5, Business and NAME ►
Professions the.
❑ 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). r?'6 9 9 A
OWNER
,❑ I,as owner of the property,am exclusively contrcidingMAIL o a o 8
with licensed contractors to construct the'project (Sec- (ADDRESS
tion'7044., Business and Professions Code). 30 50
CONSTRUCTION LENDING AGENCY CITY TEL. NO
I hereby-affirm that there is a construction lending agency for c u I o J 0.9 06
the performance of the work for which this permit is issued CONTRACTOR
(Sec. 3097, Civ. C.). ,' 0 7.1.3- g 4
ADDRESS
Lender's'Name
CI � J.
Lender's Address
I certi f •that I have read this a lication and state that the t E LIC.
above information is correct. I agree to comply with all County LICENSE NO. CLASS (�•�.
ordinances and State laws relating to building construction,
and hereby authorize representatives of this.County to enter
po abov - nti ned p pert for inspecti purp ses. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date