HomeMy Public PortalAbout6033 ROWLAND AVE_Mechanical__ WORKkRS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
'•_g�� ure,Lohave a Sec.�3800, Lab. C.) 76A364Claafcertif cairm tte of Workers'tlCampensallon Insuran eficate of consent to lf
or a cert la copy thereof( HEATING - VENTILATING - AIR CONDITIONING
CE-818(REV. 10/81)
Policy No. Company
Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
❑ Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING Q
tion department. (PRINT OR TYPE ONLY) ADDRESS D✓
Date Applicant - 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 DISTRICT NO. PROCESSED BY
the permit is for one hundred dollars($100)or less.) l.�L ��
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM J
permit is issued, I shall not employ any person i any manner
so as to become subject to the O rs COm fs7sathaws. BOILER, BTU APPROVALS DATE I b'PECTO SIGNATURE
� COMPRESSOR,BTU ✓ D� ROUGH
Date App�lif ant
NOTICE TO APPLICANT: I afte making this Certificate of VENTILATION SYSTEM FINAL
Exemption, you shout `beco a subject to the Workers'
Compensation provisio s of a Labor Code, you must forth- EVAPORATIVE COOLER VALIDA ION
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED-UNIT-
'(commencing
USPENDED UNIT'(commencing with Section 7000)of Division 3 of the Business - WALL
and Professions Code,and my license is in full force and effect. L dIL
License Number Lic. ClassPoo- V
0
Contractor Date 7 a 8 A V
❑ I am exempt under Sec. AU
Plan check fee # a a o a a 8CL
B.&P.C. for this reason' �
Date:
PERMIT ISSUING FEE$ Q I a a 30,50
-
Signature TOTAL FEE a o.'0 3 0 5 0 5
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT 0 5,2 7 1 8 7
I hereby affirm that i am exempt from the Contractor's License ,
Law for the following reason (Section 7031.5, Business and NAME
Professions Code):
❑ I, as owner of the property, or my employees with ADDRESS
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
1,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 AGENCY CITY _ TEL. NO.��,
I hereby affirm that there is a construction lending agency for U ►
the performance of the work for which this permit is issued CONTRACTOR
(Sec. 3097, Civ. C.).
ADDRESS
Lender's Name
CITY TEL. NO.
Lender's Address
STATE LIC.
I certify that I have read this application and state that the LICENSE NO.. CLASS
above information is correct. I agree to comply with all County
ordinances nd State laws relating to building construction,
a re autho' repr antatives of this County to enter
up above- ntio property for ins a tion p rposes, SEE REVERSE FOR EXPLANATORY LANGUAGE
J
"Ig 21v
Si lure of Applicant or Agent Date