HomeMy Public PortalAbout9108 RANCHO REAL RD_Mechanical_1989-01-16 WO!-KERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
y affifm that I have a certificate of consent to self
:5 insure 6r a certificate of Workers'Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
ora certifidtl copy thereof(Sec:3800 Lab. C. 76A364C
p� i / CE-818(REV. 10/81)
Policy Nb!�o; ny X
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 n ` /
J
tion arimenf. (PRINT OR TYPE ONLY) ADDRESS P ,
Date —'79Applicant LOCALITY t
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE r
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.) V (/
I certify that in the performance of the work for which this ' AIR HANDLING UNIT,CFM lJ a
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 SP cTOR'S SIGNATURE
Date /►pplicant COMPRESSOR, BTU 00 ! 19ROUGH '
NOTICE 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 VALID N
with comply with such provisions or this permit shall be,
deemed revoked. FURNACE: FAU RAVITY /I �y]1
LICENSED CONTRACTORS DECLARATION FLOOR TU (/ 0
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.
/�' r 0
License Numbe��/C7Lic. Class /._ _ 1�� , 0U
/
Contract d tw, 46
ate
❑ I am exempt under Sec.
Plan check fee
B.BP.C. for this reason' VAZ
Date:
PERMIT ISSUING FEE$
'
Signature TOTAL FEE
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License 7 ,
Law for the following reason (Section 7031.5, Business and NAME
Professions Code): 17
❑ I, as owner of the property, or my employees with ADDRESS 2 , /
wages as their sole compensation,will do the work and
the structure is not intended or offered for sale(Section CITY ��2 TEL.N0;I �i
7044, Business and Professions Code).
El 1,
I, as owner of the property,am exclusively contracting ACCT,
with licensed contractors to construct the project (Sec- MAIL / t �� 3307 51.5li
tion 7044, Business and Professions Code). ADDRESS
CONSTRUCTION LENDING AGENCY CITY e " ` TEL.NPT- �` •I ITEMS
EMS
I hereby affirm that there is a construction lending agency for it �- ��i f
the performance of the work for which this permit is issued CONTRACTOR T I_iTN, -e m -
(Sec. 3097, Civ. C.). r• 1 (a,00ADDRESS ('ASH
Lender's Name 2 7 �L�r� c 48.50
CITY 4 TEL'.
Lender's Address _
i s �
I certify that I have read this application and state that the LICENSE NO. � ( S CLASS awl. ; ('111—i't',-11� J-/16/89
above information is correct. I agree to comply with all County ( ' ' !__
ordinances and State laws relating to building construction, r
��ti•f^ 1 AMID:,:tom
and hereby authori representatives-of this County to enter i
the ab ve-m tion property for in7`71
urposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
lR..��'CC�� -<79=_;10
Signature of Applica- or Agent Date _ .