HomeMy Public PortalAbout4935 RYLAND AVE_Mechanical__ WOJtKECOMPENSATION DECLARATION APPLICATION FOR PERMIT
I heyeby"affirm that I have a certificate of consent to self , •
Insure, of4o certificate of Workers'Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
ora certified copy thereof(Sec. 3800, Lab.C.) 76A364C
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 ,p �4N�
tion department. (PRINT OR TYPE ONLY) ADDRESS IQ
Date Applicant LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST '
COMPENSATION INSURANCE CROSS ST. L,dW 6-1Q
(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($100)or less.) AIR HANDLING UNIT,CFM `
I certify that in the performance of the work for which this J t/
permit is issued, I shall not employ any person in any manner
so as toee become subject to the Workers'Compensation Laws. J BOILER,BTU /f APPROVALS DATE INSP OR'S SIGNORE
Date bl J ApplicantI1W l COMPRESSOR,BTU d U ROUGH G -
NOTICE fO A LICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code., you must forth- EVAPORATIVE COOLER VALIDAT N
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU !�L;—GRAVITY '. /�`,
LICENSED CONTRACTORS DECLARATION FLOOR BTU (� �V
I hereby affirm that I am'licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT t
'(commencing with Section 7000)of Division 3 of the Business - WALL
and Professions Code,and my license is in full force and effect.
0
License Number Lic. Class ,
®C
ContractorDate
I am-exempt under Sec.
Plan check fee
rA
B.&P.C. for this reason PERMIT ISSUING FEE$ I
_ a v.
Date: ,
Signature TOTAL FEE jf
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT 3 5 0 2 A
I hereby affirm that I am exempt from the Contractor's License 7 1 , # o '0 0 0 0 8
Law for the following reason (Section 7031.5, Business and NAME
Professions Code): 1003050
Imo'
IAI I, as owner of the property, or my employees with L
ADDRESS
wages as their sole compensation,will do the work and 7 081 0 0 0 3 0'5 0 0
the structure is not intended or offered for sale(Section CITY T TEL. NO.
7044, Business and Professions Code). OWNER I' 1. 19—85
❑ 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. NO.
I hereby affirm that there is a construction lending agency for
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 and State laws relating to building construction,
and hereby authorize representatives of this County to enter
upon the above-mentione property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date