HomeMy Public PortalAbout5118 ROSEVALE DR_Mechanical__ WORKERS COMPENSATION DECLARATION APPLICATION FOR PERMIT
I hgrebyvm affthat I have a certificate of consent to self
insure or a certificate of Workers' Compensation Insurance
or a certified copy thereof (Sec 3800 Lab C ) 76A364C HEATING - VENTILATING - AIR CONDITIONING
CE 818(REV 10/81) -
P❑olicy No Company
Certified copy is hereby furnished COUNTY OF LOS ANGELES BUILDING AND SAFETY
❑ Certified copy i;filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING p7
tion department (PRIM OR TYPE ONLY) ADDRESS o
Date Applicant LOCALITY
NO TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS STIt-
(This section need not be completed If the work Involved by ABSORPTION UNIT BTU-- DISTRICT NoPROCESSED BV
the permit Is for one hundred dollars($100)or less ) ^
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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 BOILER BTU
so as to becomesubjectto the Workers''Compensationw
/ Las /� APPROVALS DATE s SIcNA RE
Dot.-6::. /applicant —F'� N��./�� COMPRESSOR BTU 7La'�U 00 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 VALIDA ON
with comply with such provisions or this permit shall be
deemed revoked FURNACE FAU VI
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER SUSPENDED UNIT_
(commencing with Section 7000) of Division 3 of the Business WA L Y
and ProfessionsCode and my license is in full force and effect6AMW- n / ` d
License Number;Z �� Uc Class e-2—.0Y / V ► U
c rt oat Z6�B'?
❑ I am exempt under Sec W
Plan check fee d
B 8P C for this reason Wit
PERMIT ISSUING FEE $ Z
Dote
Signature I TOTAL FEE 8 7 0 9.8 A
OWNER-BUILDER DECLARATION PAN CHECK APPLICANT # st• s e 8
1 hereby affirm that I am exempt from the Contractor s License ►
Law for the following reason (Section 7031 5 Business and NAME I • * 4800
Professions Code)
❑ I, as owner of the property or my employees with ADDRESS s s s 4 8 0 0 iS
wages as their sole compensation,will do the work and
the structure is not intended or offered for sole(Section CITY TEL NO Cy 2 b�,8 7
7044 Business and Professions Code)
❑ Ov NER
I as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec MAIL
tion 7044 Business and Professions Code) ADDRESS
CONSTRUCTION LENDING AGENCYI
CITY TEL NO
I hereby affirm that there iso construction lending agency for ,
the performance of the work for which this permit Is issued CONTRACTO
(Sec 3097 Gv C ) -
ADDRESS
Lender s Nome
CITU ,��oyr
Lander s Address TEL
STA C
I comfy that I have read this application and state that the LICENSE NO .�
above information is correct I agree to comply with all County
ordinances and State laws relating to budding construction
and hereby authorize representatives of this County to enter
uponth�ybove-menti ned pr perty for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE _
Stgnewre of Applicant or Agent Date -