HomeMy Public PortalAbout9018 RANCHO REAL RD_Mechanical_1990-01-05 WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
t , I hereby affirm that I have a certificate of consent to self
insur&, or a certificate of Workers'Compensation Insurance, HEATING - VENTILATING -, AIR CONDITIONING
76A364C
orp ' 'ed copy thereof(Sec. 3800, Lab. C.) �
L . CE-818(REV. 10/81)
Policy o. ( (� Company C U/ COUNTY OF LOS ANGELES I BUILDING AND SAFETY
Certified copy is hereby furnished.
Certified copy is filed with the county building inspec- FOR APPLICANT TO FILVIN BUILDING
ton department. ADDRESS S
(PRINT OR TYPE ONLY)
14— [d Applicante�/lL�.�4)04� LOCALITY �ll
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST. �7
(This section need not be completed if the work Involved by ABSORPTION UNIT,BTU DISTRICT NO. PROLE
the permit Is for one hundred dollars($100)or less.) t AIR HANDLING UNIT,CFM
I certify that in the performance of the work for which this �.
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 INSPECTOR'S SIGNATURE
COMPRESSOR,BTU ROUG y
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL it
Exemption, you should become subject to the Workers' r _-
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VAL"0ATIO1�!
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU AVITY
LICENSED CONTRACTORS DECLARATION 1 FLOOR BTU
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 full force and effect.
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License Number. � Lic. Clas Cot U � t
4,Y
Contractor �e 0d-40009 D7V
1�
❑ I am exempt under Sec. Plan check fee 9L
B.BP.C. for this reason' PERMIT ISSUING FEES D
Date: to
Signature I TOTAL FEE
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and NAME
Professions Code):
❑ I, as owner of the property, or my employees with ADDRESS !'i 4Tn8
wages as their sole compensation,will do the work and CITY tr TEL. NO. 331�7 2 t:(�
the structure is not intended or offered for sale(Section ,1,.�
7044, Business and Professions Code). /�,� Q 'rpt
OWNER d- q- MAS in0 X/�? � 1 1 1 GI tS
❑ I, as owner of the property,am exclusively contracting -F' i
with licensed contractors to construct the project (Sec- MAIL ADDRESS U� Z)ACf/V? e� TOTAL 23.50
tion 7044, Business and Professions Code) .
CONSTRUCTION LENDING AGENCY _CITY Q �'�'f TEL. NO.� 31 f CHECK23.5'
I hereby affirm that there is a construction lending agency for e
the performance of the work for which this permit is issued CONTRACTO �. eC0,41 ,11L fPl2 .IAN, ► CHANGE
(Sec. 3097, Civ. C.).
ADDRESS
Lender's Name /� y� � ��r� ,�ry i
CITY /p� /� C /�/ TEL. NO. 8070 1 f� e°
Lender's Address STATE LIC. �t n 17
1 certify that I have read this application and state that the LICENSE NO. V 3y CLASS Sno o
above information is correct. I agree to comply with all County
ordinances and State laws relating to building construction,
and hereby authorize re resentatives of this County to enter
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n t e above-me' n d.property for inspection p rposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
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Signature of Applicant or Aent Date
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