HomeMy Public PortalAbout9116 RANCHO REAL RD_Mechanical_1986-09-10 40% 'Uf/ORURS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
4-hereby%affkm That I have a certificate of consent to self
insure,-or o certiffca�;of Workers'Compensation Insurance, HEATING - VENTILATING - AIR.CONDITIONING
or a certified ropy'thereof(Sec. 3800, Lab. C.) L 76A364C
•
Policy No. Company CE-818(REV. 10/81) _ ),
❑ 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 /4/
tion department. (PRINT OR TYPE ONLY) ADDRESS
Date Applicant I LOCALITY,�%f CC—e 7
I NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' _ NEAREST
COMPENSATION INSURANCE I CROSS ST. �11 -
(This section need not be completed if the work involved by I ABSORPTION UNIT, BTU DISTRICT NO. PR D
the permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM J
I certify that in the performance of the work for which t is
permit is issued,I shall not employ erson in y ma er BOILER,BTU
so as to become subject to the rker a ion APPROVALS DA E I PECTOR'S SI ATURE
COMPRESSOR,BTU , ' v ROUGH i
Date�"� 719' pplic n
NOTICE TO APPLICANT: If, a ter making this Ce icate of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers' "VA
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER ATI 54
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU AVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU U
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
`(commencing with Section 7000)of Division 3 of the Business WALL
and Professions Code,and my license is in full force and effect.
133 75
7s � ��� j
License Number,3 Y7, Lic. Class t.7
0
Contract •� Date ✓
❑ I am exempt under Sec. I r AU
I Plan check fee
B.&P.C. for this reason'
Date:
PERMIT ISSUING FEE$
,
TOTAL FEE 2 7S
Signature
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 I NAME
Professions Code):
El1, as owner of the'property, or my employees with ADDRESS
wages as their sole compensation,will do the work and
the structure is not intended or offered for sale(Section CITY TEL. NO.
7044, Business and Professions Code).
I OWNE eta 6
❑ I, as owner of the property,am exclusively contracting i MAIL /� /�
with licensed contractors to construct the project (Sec- a ADDRESS ( 7f! #1.54 @,•618,
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY ,J CIT7°�_ TEL. NO.�g l� - 4275
t
1 hereby affirm that there is a construction lending agency for �
the performance of the work for which this permit is issued CONTRACTOR t//f'i� f o
L
(Sec. 3097, Civ. C.).
ADDRESS `7Z 41 09. 1 0.=86
Lender's Name `
CITY•+^r� C TEL. NO. 2g/�
Lender's Address
STATELIC. •
I certify that I have read this application and state that the LICENSE NO. 75—
CLASS •'
a ation is correct. I agr to comply with all County
ordinance and State, s rela to building construction,
and h y thoriz r pre e i s of this County to enter '
up ve-me ne pec`tion purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
ignature of Applicant or Agent Date.