HomeMy Public PortalAbout6215 ROWLAND AVE_Mechanical__ I hAWORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
by offirrm;that•I hpve a certificate of consent to self
t insure, or a certificate of#porkers'Compensation Insurance, 76A364C HEATING - VENTILATING - AIR CONDITIONING
or a certified tory thereof(Sec. 3800, Lob. C.) CE-818(REV, 10/81) r
acy No. Company
Certified copy is hereby furnished. COUNTY OF'L'OS ANGELES BUILDING AND SAFETY
❑ Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING
tion department. ADDRESS
1 (PRINT OR TYPE ONLY) '
Date Applicant LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSSST.
(This section need not be completed if the work involved by ABSORPTION UNIT,BTU DISTRICT NO. of PROCIESSID EIY
the permit is for one hundred dollars($100)or less.)
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM
permit is issued,I shall not employ any p on in any manner
so as to be ome s_ubject to th:,�r ensatio S. BOILER,BTU APPROVALS DATE I Alz
CTOR'S SIG ATURE
Date l COMPRESSOR,BTU DV ROUGH
pylic
NOTI TO PPLICANT: If, after m Ing this Certific to of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: AU GRAVITY
LICENSED CONTRACTORS DECLARATION -EEAAW 009 BTU
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
'(commencing with Section 7000)of Division 3 of the Business - WALL
and Professions Code,and my license is in full force and effect. 916
O
License Number Lic. Class—
Contractor
lass Contractor Date
❑ I am exempt under Sec. U-
Plan check fee rA
B.BP.C. for this reason' f,
PERMIT ISSUING FEE$
Date:
TOTAL FEE
Signature
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT 4 7 5 O A
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and NAME , # 0 0 0 0 0 S
Professions Code): `
EDI, as owner of the property, or my employees with ADDRESS 7/ ,-�
i'a -3a5o
wages as their sole compensation;will do the work and CITY TEL. No.
the structure is not intended or offered for sale(Section .�i� �� 0 0 - 3G505
7044, Business and Professions Code).
OWNER
❑ I, as owner of the property,am exclusively contracting MAIL 0602-86
with licensed contractors to construct the project (Sec- ADDRESS/052/S- �yJ /!J
tion 7044, Business and Professions Code).
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 pop
(Sec. 3097, Civ. C.).
ADDRESS
Lender's Name c
CITY�� TEL. NO �Z675?
Lender's Address STATE 7f LIC.
I certify that I have read this application and state that the LICENSE NO .27CLASS —zo
above information is correct. I agree to comply with all County
ordinances and State laws relating to building construction,
and hereby thorize representatives of this County to enter
upo pro o e-me ed for inspection rpos s. SEE REVERSE FOR EXPLANATORY LANGUAGE
ture of
Signaplicant'or Agent Date