HomeMy Public PortalAbout9718 RICHMOND WAY_Mechanical__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
�nsurebor a certificate of Wo ke s'tCompensation Insurance,ificate of consent to lf
ora ertified copy thereof(Sec. 3800 Lab. C.)
76A364C HEATING - VENTILATING - AIR CONDITIONING
�4t�a ea�� CE-818(REV. 10/81)
Policy o. I Company COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is hereby furnished.
Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING /
tion department. ADDRESS
(PRINT OR TYPE ONLY)
00,
Date I - Applicant hp cia Q�� LOCALITY G
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 NO. PRO Y
the permit is for one hundred dollars($100)or less.), AIR HANDLING UNIT,CFM /I
1 certify that in the performance of the work for which this ✓ [ V
permit is issued,.I shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws. BOILER, BTU) t�G APPROVALS DATE IN TOR'S SIGNATURE
Date Applicant / COMPRESSOR,BTU / n ROUGH
NOTICE TO APPLICANT: If, after making this Certificate.of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU R VITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU ��•��C�
I hereby affirm that I am licensed under provisions of Chapter 9SUSPENDED-UNIT-
'(commencing
USPENDED UNIT'(commencing with Section 7000)of Division 3 of the Business HEATER: WALL
and Professions Code,and my license is in full force and effect.
C) Ob4kdu_0 916
License Number a3a(c I a _ Lic. Class ��G to
Contractor Yate 1"52
F=.
❑ I am exempt under Sec.
Plan check fee -.2 6 2 7.8 A H
B.&P.C. for this reason' PERMIT ISSUING FEE$
Date: # 0 0000 $
Signature TOTAL FEE I o o 4 a Q
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's Licerise , 0 0 0 [j $ Q(]�
Law for the following reason (Section 7031.5, Business and NAME
Professions Code):
El1, as owner of the property, or my employees with ADDRESS 01.05-87
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 �• - � ,
❑ ' I,as owner of the property, am exclusively contracting
with.licensed contractors to construct the project (Sec- MAIL
tion 7044, Business arid 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 - ,
(Sec. 3097, Civ. C.).
C
Lender's Name ADDRESS "
CITY Com,,, , r TEL. NO.
Lender's Address STATE s-v LIC. !�
I certify that I have read this application and state that the LICENSE NO. 3a(p CLASS L c
above information is correct. I agree to comply with all County
ordinances and State laws relating to building construction,
and ereby authorize representatives of this County to enter
up the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature Of Applicant or Agent Date