HomeMy Public PortalAbout5405 WELLAND AVE_Mechanical__ ti WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
i�M-hereby'q£firm that I have a certificate of consent to self
tnsJre, Qr a Sertificata 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 /
(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. r' PROCESSED BY
the permit*is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner
so asto become subject to the Workers'Compensation Laws. IBOILER, BTU APPROVALS DATE SP TOR'S SIGNA RE
Date `` Applicants COMPRESSOR,BTU ROUGH
NOTICE TO APPLICANT: If, after making this Certificate'of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION
with comply with such provisions or this permit shall be
deemed revoked. r FURNACE: FAU V Y
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
'(commencing with Section 7000) of Division 3 of the Business - WALL
and Professions Code,and my license is in full force and effect. 5
�3-� I,�5 - O
License Number Lic.'Class ® tJ
ad
Ai WWII �0�3�`�
Contractor ` O
I am exempt under ec.
Plan check fee 2 0.1 9,9 A
B.BP.C. for this reason h
Date: o,o 0 0 PERMIT ISSUING FEE$ Z`
0 8 —
Signature TOTAL FEE .1 a a 4$,0 0
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
1 hereby affirm that I am exempt from the Contractor's License ® .0 o •o 4 8,0 0 5
Law for the following reason (Section 7031.5, Business and NAME
Professions Code): o7,•1 5-88
❑ 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
❑ 1, 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. _�Mk III,
I hereby affirm that there is a construction lending agency for r
the performance of the work for which this permit is issued CONTRACTOR
(Sec. 3097, Civ. C.).
ADDRESS
Lender's Name
CITY TEL. y0.
Lender's Address
I certif that I have read this a lication and state that the STATE LIC.
y pp LICENSE NO. �2 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 the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date