HomeMy Public PortalAbout9707 RICHMOND WAY_Mechanical__ WORKERS'COMPEN6ATION DECLARATION APPLICATION FOR PERMIT
I hereby affirm that I have o certificate of consent,to self
insure, or a certificate of Workers'Compensation Insurance,pany HEATING - VENTILATING - AIR CONDITIONING
or a.certified copy thereof(Sec. 3800, Lab. C.) 76A364C
e CE-818(REV. 10/81)
P❑olicyo`J� 3��� om1 Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with th county building inspec- FOR APPLICANT TO FILL IN BUILDING of or
tion department. (PRINT OR TYPE ONLY) ADDRESS
Date f- S - 92 Applicant LOCALITY G
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS
(This section need not be'complefed If the work Involved by ABSORPTION UNIT,BTU DISTRICT NO. ESSED BY
4
the permit Is for one hundred dollars($100)or less.)
AIR HANDLING UNIT,CFM
I certify that in the performance of the work for which this �[IV
permit is issued, I shall not employ any person in any manner BOILER,BTU
so as to become subject to the Workers'Compensation Laws. APPROVALS DATE INSP 'S SIGNATUR
Date Applicant COMPRESSOR,BTU `[��y ROUGH
NOTICE TO APPLICANT: If, after making this'Certificate of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you.must forth- EVAPORATIVE COOLER VALIDAT N
with comply with such provisions.or•this permit shall be
deemed revoked. FURNACE: FAU G ITY�
LICENSED CONTRACTORS DECLARATION FLOOR BTU 3
I hereby affirm that I am licensed under provisions of Chapter 9HEATER: SUSPENDED UNIT
'(commencing with Section 7000)of Division 3 of the Business WALL
and Professions Code,and my license is in full force and effect. . J CL
License Number
3�,1 tc( � Lic. Class
IN
e ' "'. , ,
Contracto ate - -
iOJ
❑ 1 am exempt under Sec. us
Plan check fee IL
IL
B.BP.C. for this reason PERMIT ISSUING FEE$
' Date:
Signature TOTAL FEE '
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that•1 am exempt from the Contractor's License , —4 6 2 8 1 A
Law for the following reason (Section 7031.5, Business and NAME
Professions Code): # - 0 0 0 0 8
El 1, as owner of the property, or my employees with ADDRESS.
wages as their sole compensation,will do the work and o 048_00
the structure is not intended or offered for sale(Section CITY TEL. NO.
7044, Business and Professions Code). 0 0 0 4 8 0 0
-OWNER
El1, as owner of the property;am exclusively contracting MAIL �,0 Jc,-8 7with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY TEL. NO.
I hereby affirm that there is a construction lending agency for
the performance of the work for which.this permit is issued CONTRACTOR C ,
(Sec. 3097, Civ. C.). .
ADDRESS �
Lender's Name
CITY TEL. NO. _ `�y
Lender's Address •
STATE LIC.
I certify that I have read this application and state that the LICENSE NO. CLASS aD `
above information is correct. I agree to comply with all County
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter
u the. bove mentioned property for inspection purposes. SEE REVERSE.FOR EXPLANATORY LANGUAGE
f- �-Fl7
Signature of Applicant or Agent Date