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HomeMy Public PortalAbout6003 RENO AVE_Mechanical__ �WQRKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT I',hereby affirm that I have a certificate of,�Zensent,•to self insure, or a certificate of Workers'Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING orb 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 ©Q ti�iVL� (PRINT OR TYPE ONLY) Date Applicant LOCALI71t"'V (A-- C 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. P SSED BY the permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM n I certify that in the performance of the work for which this OJ/ permit is issued, I shall not employ any person in any manner BOILERBTU so as to become subject ,to the Workers'Compensation Laws. �J APPROVALS DATE INSPECTOR'S SIGNATURE Date Applicant COMPRESSOR,BTU q -W� �� V ROUGH NOTICE.TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER ALIDATI with comply with such provisions or this permit shall be deemed revoked. FURNACE: FAU LICENSED CONTRACTORS DECLARATION FLOOR I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT '(commencing with Section 7000) of•Division 3 of-the Business - WALL and Professions Code,and my license is in full force and effect. License Number Lic. Class Contractor Date ❑ 1 am exempt under Sec. LU Plan check fee IL tL y B.&P.C. for this reason' Date: s PERMIT ISSUING FEE$ Signature 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 Pro essions Code): `• I, as owner of the property, or my employees with ADDRESS ACCUr r wages as their sole compensation,will do.the work and CITY TEL.NO. -+ 7Q �fl the structure is not intended or offered for sale(Section 3307 �► �' '- 7044, Business and Professions Code). OWNER 1 ITEMS ❑ I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec- MIL TOTAL 3C) 50 tion 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY CITY TEL. NO. CHECK 30050 1 hereby affirm that there is a construction lending agency for eC�i the performance of'the work for which this permit is issued CONTRACTOR , CHANGE (Sec. 3097, Cly. C.). ADDRESS Lender's NameCITY TEL. NO. 0000—mol 10/18/89 _ 1r,1i Lender's Address STATE LIC. 6274' 1 AM 8.036 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, and hereby authori lepl;, entatives of this County to enter u on the -mentioned pro ,rty for inspection�purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Sig ature f Applicant or Agent Date