HomeMy Public PortalAbout9240 WEDGEWOOD ST_Mechanical__ WORKERS' I have a demi DECLARATION APPLICATION FOR PERMIT
I hereby affifm that I have a certificate of consent to self
insure, or a certificate of Workers'Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof(Sec. 3800, Lab. C.) '76A364C
I CE-818(REV. 10/81)
Policy Nos=Mz "ompanyL OIZ-7 1�`1}J 0
❑ Certified copy is hereby furnished. I COUNTY OF LOS ANGELES BUILDING AND SAFETY
dCertified copy is filed with the county building inspec- I FOR APPLICANT TO FILL IN BUILDING
ADDRESS Q��,
tion department. (PRINT OR TYPE ONLY)
Date p licanT LOCALITY `
NO. TYPE OF APPLIANCE OR EQUIPMENT • FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE I 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($100)or less.)
AIR HANDLING UNIT,CFM
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner "
so as to become subject to the Workers'Compensation Laws. BOILER,BTU APPROVALS DATE INSPECTOR'S SIGNATURE
I
COMPRESSOR,BTU ROUGH
Date Applicant-
NOTICE
pplicant NOTICE TO APPLICANT: If, after making this Certificate of I VENTILATION SYSTEM FINAL 2 --
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION j FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: DED UNIT
'(commencing with Section 7000)of Division 3 of the Business WALL +�(� �-�
and Professions Code,and my license is in full force and effect.
License Number ZQC��� Lic. Class ® U
Contractoro N\ V!2_1_% Date S:—k —ta
❑ 1 am exempt under Sec. LIM
V
Plan check fee Is
U)
B.&P.C. for this reason' I Date: ZPERMIT ISSUING FEE$
TOTAL
OTAL FEE
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and I NAME
Professions Code):
❑ I, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and 1 2
CITY TEL. NO. i;e u o o a P
the structure is not intended or offered for sale(Section ; ,,c
7044, Business and Professions Code). ;
i OWNER
❑ 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 VNA
the performance of the work for which this permit is issued CONTRACTOR
(Sec. 3097, Civ. C.).
ADDRESS
Lender's Name 1..,1,��,71<7_1
Lender's Address
N CITY TEL. NO.
I certifythat I have read this application and state that the STATE LIC.
pp 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
on the ove-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date