HomeMy Public PortalAbout5403 WELLAND AVE_Mechanical__ :{ PINORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
�'�• I beq`oy••affkm that I have a certificate of consent to self
" `+;hsure, or,ed copy thereof (Sec. 3800, Lab. C.) 76A364C p certificate of Workers'Compensation-insurance, HEATINGNENTIdATING - AIR CONDITIONING
or a certifi .
CE-818(REV. 10/81)
Policy No. Company COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is hereby furnished. _
❑ Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING
tion department. ` (PRINT OR TYPE ONLY) ADDRESS
Date ApplicantLOCALITY
,NO. TYPE OF APPLIANCE OR EQUIPMENT FEE NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS'
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($100)or less.)
AIR HANDLING UNIT,CFM /�
[!
permit is issued, I shall not employ any person in any manner BOILER,BTU
so as to become subject to the W rkers'Compensation Laws. APPROVALS DATE INS OR'S SIGN URE
Date +'J L1_VRApplicant �COMPRESSOR,BTU L � ROUGH ..
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU Qa61T
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
'(commencing with Section 7000) of Division 3 of the Business - WALL
14 F
and Professions.Code,and my license is in full force and effect.
49 q0
License Number Lic. Class
r
Contractor to
20198A 0!Q-,5()-q0
❑ I am exempt under Sec. # o 0 0 0 0 8 V
Isl1
Plan check fee 1 0 - 48.00
B.&P,C. for this reason PERMIT ISSUING FEE$ �
Date: 0 0 - 4a00
v
TOTAL FEE
Signature
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT .0 715"8 8
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):. t
❑ 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).
OWNER
❑ I, as owner of the property, am exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRESSa RA
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY w 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. 6-
Lender's Address
STATE LIC. '
I certify that I have read this application and state that the LICENSE NO. (, CLASS C
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-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date