HomeMy Public PortalAbout10106 RANDWICK DR_Mechanical__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
I herebyaffirm that I have a certificate of consent to self
insure, or a cert'if'icate of Workers'Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
/o�r a rtified cop thereof(Sec. 3800, Lab. C.) y„ 76A364C
'P P Y&��K/��• CE-818(REV. 10/81)
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❑ 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
[,�_,t' department. �j (PRINT OR TYPE ONLY) ADDRESS `
Date / `% Applicant �C� LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FR6M WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST.
(This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO. c� PROCESSED BY
the permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM i
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner BOILER, BTU
so as to become subject to the Workers'Compensation Laws. ee APPROVALS DATE INSPECTOR'S SIGNATURE
l COMPRESSOR,BTU 3b i�� ROUGH
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL G
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VIALI 'ATO
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAUGRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9SUSPENDED UNIT
HEATER:
`(commencing with Section 7000)of Division 3 of the Business WALL
and Professions Code,and my license is in full f rce pnd effect., d
License Number 6yo%.� C.Clas �✓� , U
.-9 / 0
Contractor ate
❑ I am exempt under Sec.
Plan check fee �
o.
B.BP.C. for this reason Date: J z
PERMIT ISSUING FEE$
Signature TOTAL FEE .t
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT F
I hereby affirm that I am exempt from the Contractor's License , ACC i°7
Law for the following reason (Section 7031.5, Business and NAME 33I37 25 1`(a
Professions Code): ADDRESS I iTl=•1 t'�e,�
El1, as owner of the property, or my employees with
wages as their sole compensation,will do the work and CITY TEL. NO. TOTAL 5 a CID
the structure is not intended or offered for sale(Section -
7044, Business and Professions Code). CHECK °�1�.
OWNER
❑ I, as owner of the property, am exclusively contracting MAIL CHANGE °1113
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY TEL. NO. 1 v I I CII ' I r•
ACCO- C��. 1�. 1:9t.
I hereby affirm that there is a construction lending agency for
7 N Q°t:'�
the performance of the work for which this permit is issued CONTRACTOR ( i / �l� f ;111 v° ar
(Sec. 3097, Civ. C.). / '
ADDRESS ,
Lender's Name J
CITY TEL. NO.
Lender's Address
STATE LIC.
I certify that I have read this application and state that the LICENSE NO. CLASS
above information is correct. I agree to comply with all County
ordinances and State laws relating to building construction,
a ereby authorize resentatives of this County to enter
o e above me propertAw.te oses. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent