HomeMy Public PortalAbout5401 WELLAND AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION, APPLICATION FOR PERMIT
"F''hereby affirm 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
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
ADDRESS
tion department. .12
(PRINT OR TYPE ONLY)
Date Applicant LOCALITY c f
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE dr
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 permit is'for one hundred dollars($100)or less.) �
AIR HANDLING UNIT,CFM v
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner BOILER,BTU
so as to become subject to the Workers'Compensation Laws. APPROVALS DATE NSP TOR'S SIGNAT RE
G COMPRESSOR, BTU �7•Z t`� O O ROUGH
Date'--� /�J / "y�plicant yetec �v�'
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION
with comply with such provisions or this permit shall be
deemed revoked. J FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION [ FLOOR BTU' [CJ
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
'(commencing with Section 7000)of Division 3 of the Business WALL 201 97R
and Professions Code,and my license is in full force and effect. �7l 916LL 44iPohz� Q J(/ #.oeeoc8 O
License Number Q-3 Z`'/Z Lic. Class C t)
I 4a00
Contractor Date a c a 4 ()0'0 u
❑ I am exempt under Sec.
Plan check fee
B.&P.C. for this reason- PERMIT ISSUING FEE$ 0
Date:
LIN Q)
Signature TOTAL FEE
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that.1 am exempt from the Contractor's License S
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 CITY TEL. NO.
the structure is not intended or offered for sale(Section
7044, Business and Professions Code).
OWN
❑ 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 CIJ TEL. NO.�
I hereby affirm that there is a construction lending agency for - 3;
the performance of the work for which this permit is issued CONTRACTCI
(Sec. 3097, Civ. C.).
ADDRESS
Lender's Name
CITY
Lender's Address EL. NSTATEO.e� /
I certify that I .have read this application and state that the LICENSE �Z4! , 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 t e bove-mentioned property for inspection
/purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date