HomeMy Public PortalAbout9714 RICHMOND WAY_Mechanical__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT i
I hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers'Compensation Insurance, 7sAseac HEATING - VENTILATING . AIR CONDITIONING
or a certified co thereof(Sec. 3800, Lab. C.}
W 5 a IOU,9� CE-818(REV. 10/81)
P❑ailcy No. Z / Company e�L' rl^116Y11 - ,
Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
�IAJ Certified copy is filed with th county building inspec- FOR APPLICANT TO FILL IN BUILDING
tion department. (PRINT OR TYPE ONLY) ADDRESS
Data ``� 7 Applicant f- LOCALITY
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 I DISTRICT NO. Pijq BY
the permit is for one hundred dollars($100)or less.)
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM'
permit Is issued,I shall not employ any person in any manner
so as to become subject to the Workers"Compensation Laws. BOILER'BTU APPROVALS DATE XINSPEYMS SIGNATURE
Date Applicant COMPRESSOR, BTU ROUGH r
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATI N
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU t G 1(ITY
LICENSED-CONTRACTORS DECLARATION FLOOR BTU � 1tiC
1 hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED-UNIT-
'(commencing
USPENDED UNIT'(commencing with Section 7000) of Division 3 of the Business - WALL
and Professions Code,and my license is In full force and effect.
ca� ( �� Lic. Class �- c U
License Number t r%
Contractor Ln
❑ I am exempt under(ec.
Plan check fee 2 b 2 7,9 A N
B.&P.C. for this reason' PERMIT ISSUING FEE$ �
Date: # o,0 0 0 0
Si nature TOTAL FEE
g 1 o 0 48,00
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License 0 0 - 4a003.
Law for the following reason (Section 7031.5, Business and NAME
Professions Code):
❑ I, as owner of the property, or my employees with ADDRESS a 1,05_87
wages as their sole compensation,will do the work and CITY TEL NO
the structure is not intended or offered.for sale(Section
7044, Business and Professions Code). -
OWNER a nx N' ,
❑ 1,as owner of the property,am exclusively contracting w AL '
with licensed contractors to construct the project (Sec- MAIL
tion 7044, Business and Professions Code). ADDRESS
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 ( 4
(Sec. 3097, Civ. C.).
ADDRESS T s RI
Lender's Name nn
CITY Lg„k TEL.NO.
Lender's Address Y
STATE LIC.
I certify that I have read this application and state that the LICENSE NO. CLASS - r7
above information is correct. I agree to comply with all County
ordinances and State laws relating to building construction,
andh eby authorize representatives of this County to enter
upon abo a-m boned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date