HomeMy Public PortalAbout9230 WEDGEWOOD ST_Mechanical__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
-1 hergbv offi•rm that I have a certificate of consent to self
'Insure, or a 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
tion department. ADDRESS
P (PRINT OR TYPE ONLY) �
Date Applicant LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST r ,
COMPENSATION INSURANCE CROSS ST.
(This section need not be completed If the work involved by ABSORPTION UNIT, BTU DISTRICT NO. Y/ PROCESSED BY
the permit is for one hundred dollars($100)or less.) 5UJ/
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM '
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers'7Compensation Laws. BOILER, BTU APPROVALS DATE I SP OR'S SIGNATURE
Date 6 Applicant / COMPRESSOR, BTU ROUGH �j
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL ✓z
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAUGRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
'(commencing with Section 7000)of Division 3 of the Business WALL
and Professions Code,and my license is in full force and effect.
O
License Number Lic. Class S ��j i� O� , U
Contractor Date
F-1I am exempt under Sec. UJ
V
Plan check fee
B.BP.C. for this reason'
PERMIT ISSUING FEE$ (J
Date: TOTAL FEE W S
Signature
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT L�S
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): 272-29A
'
�IADDRESS 1 / ag-oo
as owner of the property, or my employees with 'Of 112 Lv
wages as their sole compensation,will do the work and R p�P�l� o 0 0 0 0
the structure is not intended or offered for sale(Section CITY d TEL. NO. d
7044, Business and Professions Code). �/J j
OWNER C/, /7` LGL it„/„ucj '( 0 0 2 x 5 0
❑ I,as owner of the property, am exclusively contracting MAIL /�)
with licensed contractors to construct the project (Sec-
ADDRESS �() W w a o _
tion 7044, Business and Professions Code). 0 0 0 2 a 5 v
CONSTRUCTION LENDING AGENCY CITY TEL. NO.
1
1 hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued CONTRACTOR ® o 6-1 1 -87
(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 her y out
representatives of this County to enter
o t a e-mentioned property for ins ection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date