HomeMy Public PortalAbout9723 RICHMOND WAY_Mechanical__ c vORKEthat
COMPENSATION DECLARATION APPLICATION FOR PERMIT
I hereby affirm that I have a certificate of consent to self '
insure, or a certificate of Workers'Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
or a c@rt'fied copy thereof(Sec. 3800 Lab. C.) 76A364C
( No 3T3 2 �A �C i
PolicCertified copy is hereby furnished.d. CE-818(REV. 10/81)
yy No. company COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with thecounty building inspec- FOR APPLICANT TO FILL IN BUILDING -�
CC ADDRESS
tion department. (PRINT OR TYPE ONLY)
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Date I-S - 7 Applicant � LOCALITY PW--G
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST /
COMPENSATION INSURANCE CROSS . L
(This section need not be completed if the work involved by ABSORPTION UNIT,BTU DISTRICT NO. {,// P SSED v
the permit is for one hundred dollars(;100)or less.) AIR HANDLING UNIT,CFM o
I certify that in the performance of the work for which this
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 DATENS O*SIGNATE
Date Applicant COMPRESSOR, BTU g1f6& ROUGH
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workeis'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDA ON
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU ]y OU
I 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. _.) d
G.. A. - Ci(- u
License Number p` 3 z a1 Lic. Class Ca r
Contractor kC Date "ay 7 O
f°
❑ I am exempt under Sec. V
W
Plan check fee 6 2£3 6 A °-
h
B.BP.C. for this reason Date: �
PERMIT ISSUING FEE $ , # o 0 o e o 8
Signature TOTAL FEE o,o4 8 O Q
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License 0 0 0 (( $ Q
Law for the following reason (Section 7031.5, Business and NAME
Professions Code): 0 1,0 5=8 7
❑ I, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and
the structure is not intended or offered for sale(Section CITY TEL.NO.
7044, Business and Professions Code).
OWNE
❑ I, as owner of the property, am exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code). _
CONSTRUCTION LENDING AGENCY CITY TEL
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued CONTRACTOR G
(Sec. 3097, Civ. C.).
ADDRESS
Lender's Name ������
CITY ' TEL. IS
Lender's Address
STATEI certify that I have read this application and state that the LICENSE NO. LIC."a7Z 6, CLASS
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
upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent. Date
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