HomeMy Public PortalAbout9506 WEDGEWOOD ST_Mechanical__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT ' C�� ®�
,....I hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers'Compensation Insurance, I HEATING - VENTILATING - AIR CONDITIONING
or a 6ertified 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 th county building inspec- FOR APPLICANT TO FILL IN BUILDING
tion department. ADDRESS a AL)Ooda,
(PRINT OR TYPE ONLY)
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 permAIR HANDLING UNIT,CFM
It is for one hundred dollars($100)or less.) S
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner v U
so as to become subject to the Work rs'Compensation Laws. BOILER, BTU APPROVALS DATE INSP T 'S SIGNATURE
Date Applicant COMPRESSOR, BTU ROUGH
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL Zalze
�G
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER 6#A 1 In ATIQN
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION POOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED—UNIT—
"(commencing
USPENDED UNIT'(commencing with Section 7000)of Division 3 of the Business WALL (�
and Professions Code,and my license is in full force and effect. d
License Numb r `�� Lic. Class , V
Contracto ate A
❑ I am exempt under Sec. V
Plan check fee a
BAP.C. for this reason' PERMIT ISSUING FEE$
Date:
Signature TOTAL 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 NAME
Professions Code):
❑ I, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and
the structure is not intended or offered for sale(Section CITY TEL. NO.
7044, Business and Professions Code). e
OWNER LN C CV ti? ! yt i.50
El 1, as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec- MAIL
ADDRESS9 J4/{p 011d d i icu-
tion 7044, Business and Professions Code). EDITS
CONSTRUCTION LENDING AGENCY CITY TEL. �� i f 513
I hereby affirm that there is a construction lending agency for n(, 50
the performance of the work for which this permit is issued CONTRACTOR u O
d. ✓CST. CHECK ''
(Sec. 3097, Civ. C:). f H��'��1r el 10
Lender's Name
ADDRESS J T� s t/t 4 -
�
CITY wvsr ttf�V/ve¢ TEL. N .�
Lender's Address t
STATE y �r7 LIC. l 0 l0—I 4 01]1
I certify that I have read this application and state that the LICENSE NO. TjL CLASS 1'a Ni-I
C•
above information is correct. I agree to comply with all County �=1
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter
up n the e-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE,
Signature of Applicant or Agent Date