HomeMy Public PortalAbout9063 RANCHO REAL RD_Mechanical_1988-11-04 WORKERS'COMPENSATION DECLARATION (.� r L t
I hereby affirm that I have a certificate of consent to self APPLICATION FOR PERMIT ,
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
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. ADDRESS
(PRINT OR TYPE ONLY)
LOCALITY
Date Applicant
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST.
(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.) 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 BOILERBTU
so as to become subject to the Workers ,Compensation Laws. APPROVALS DATE IN PE R'S SIGN URE
Date —A' ,
' pplicant �.�–�_ COMPRESSOR, BTU V ROUGH
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM v FINAL
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDAT AO_Fd
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisigns of Chapter 9 HEATER: SUSPENDED UNIT
'(commencing with Section 7000) of Division 3 of the Business WALL
and Professions Code,and
��m��ykklicense is in full force and effect. IL
License Number I`" 466 Lic. Class V CS"a-k b I ► U
------���-�' 2 l-r/.JGt�Date — - 1 O b 9 A F
Contractor�7►� # 8 O
❑ I am exempt under Sec. IL
Plan check fee ua
I o o 4 Q 5 0
H
BAP.C. for this reason' PERMIT ISSUING FEE co -4 (15055
Date: ,
Signature TOTAL FEE G 1 1. 04-88
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's L1.;-ense ,
Law for the following reason (Section 7031.5, Businc,�s and NAME
Professions Code):
❑ I, as owner of the property, or my emplo✓aes with ADDRESS
wages as their sole compensation,will do th.,vork and
the structure is not intended or offered forlIble(Section CIN TEL. NO.
7044, Business and Professions Code). I t
OWNER g W C P7 J
❑ I; as owner of the property, am exclusively contracting MAIL _ �y " ��
with licensed contractors to construct tI,a project (Sec- ADDRESS ?j rC.EwtC�lvO
tion 7044, Business and Professions Cocle).
CONSTRUCTION LENDING AGENCY ' CITY�� i' TEL. NO.Q' �_
I hereby affirm that there is a construction lending agency for `���ryy
the performance of the work for which thil permit is issued I CONTRACTOR
(Sec. 3097, Civ. C.).
ADDRESS
Lender's Name
CITYc,�p TEL. NO. S�((
Lender's Address STATE - LIC. + r�v
I certify that I have read this application,and state that the LICENSE NO. ( CLASS Y c C-tG-?,O-i+
above information is correct. I agree to cor-iply with all County
ordinances and State laws relating to bu ding construction,
and hereby authorize representatives of this County to enter
upon the above-mentioned property for i•tspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date