HomeMy Public PortalAbout6266 ROSEMEAD BLVD_Mechanical__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
yil hereby affifm that I have a certificate of.consent to self
insure, or a certificate of Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
or a cert" "ed copppyyy there f(Sec. 3800, La C,_L 76A364C \
y �q ^P y ���CE-818(REV. 10/B1)
Folic N ( om an COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is hereby furnished.
Certified copy is filed with the unty building i ec- FOR APPLICANT TO FILL IN BUILDING
tion department. ADDRESS
(PRINT OR TYPE ONLY)
/ LOCALITY
Date G Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE ;eAze,
CE IFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS,ST. �(,dN J✓
ABSORPTION UNIT, BTU DISTRICT NO. PROCESSED BY
(This section need not be completed if the work involved,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 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 (i° APPROVALS DATE INP OR'S SIGNATURE
COMPRESSOR, BTU / ROUGH
Date Applicant
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 VALIDATIO
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU
-
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED—UNIT—
(commencing
USPENDED UNIT(commencing with Section 7000) of Djvision 3 of the Business WALL
and Professions Code-and my license is.in full force and effect.
License NL er.9611006 - Lic. Class
Contractorllppaz_0 11�1�Date O
f�
❑ I am exempt under Sec. us
Plan check fee
B.&P.C.'for this reason ,7j 8 2 6 A 4A
4! PERMIT ISSUING FEE $ �d
D e
TOTAL FEE #` 0 0 0 a a 8
Signature
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT 0.0 3 0 5 0
I hereby affirm That I am exempt from the Contractor's License ' 0 0 a 3 Q 5 0 F-'I
Law for the following reason (Section 7031.5, Business and NAME
Professions Code):
❑ I, as owner of the property, or my employees with ADDRESS �' 4—8 6
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).
OWNER .O �1
ElI, as owner of the property, am exclusively contracting
with licensed contractors to construct the project'(Sec- MAIL f
tion 7044, Business and Professions Code). ADDRESS C7
CONSTRUCTION LENDING AGENCY CITY �J TEL. N0.5� � -
I hereby.affirm that there is a construction lending agency for F
the performance of the work for which this permit is issued CONTRACTOR L A-6
(Sec. 3097, Civ:C.).
ADDRESS �( f
Lender's Name �f
CITY �} ��� TEL. 7v
Lender's Address /
STATE / LIC.
I certify that I have read this application'and state that the LICENSE NO. la 0 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 '
upo/n//y'/�LIeabove-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
/
Signature of Applicant or Agent Date kJ .