HomeMy Public PortalAbout5562 WELLAND AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
.� 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. 38(1% Lab. C.) 76A364C
CE-818(REV. 10/81)
Policy No. Comport
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 �I'1
tion department. (PRINT OR TYPE ONLY) ADDRESS
Date Applicant LOCALITY C
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST. I
(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($100)or less.)
AIR HANDLING UNIT,CFM
I certify that in the performance of the work for which this t 6�' 1-1v
permit is issued, I shall not employ any person in any manner BOILER, BTU
so as to become subject to the Workers'Compensation Laws. APPROVALS DATE I CTOR'S SIGNATURE
Date Applicant COMPRESSOR,'BTU m D ROUGH ✓
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL ��
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDA'rt^N
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU GRAVITY 11
LICENSED CONTRACTORS DECLARATION FLOOR BTU a
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
'(commencing with Section 7000) of Division 3 of the Business WALL
and Professions Code,and tmny license is in full force and effect.
License Number LIT-1 100S Lic. Class ® 4J
/��r I �
Contractor ENC` Date ` O
❑ X8410 A
I am exempt under Sec.
Plan check fee # ° ° ° °.° 8 y
B.&P.C. for this reason' ;EPERMIT ISSUING FEE$ ,
Date: 3 Q 5 0
TOTAL FEE
Signature s, 0 oo 30(�
• .5050.
OWNER-BUILDER DECLARATION PIAN CHECK APPLICANT '
I hereby affirm that I am exempt from the Contractor's License .^ t 1.30-87
Law for the following reason (Section 7031.5, Business and NAMECpffi�Z , '
Professions Code):
ADDRESS '-
❑ I, as owner of the property, or my employees with 1 Z
wages as their sole compensation,will do the work and CITY, TEL. NO. _)5—\4S5
the structure is not intended or offered for sale(Section 1
7044, Business and Professions Code). ^ V\
1I+V�
❑ I., as owner of the property, am exclusively contracting (-,
OWNER
with licensed contractors to construct the project (Sec- MAIL
ADDRESS , 1
tion 7044, Business and Professions Code). - 1 1
CONSTRUCTION LENDING AGENCY CITY�G C( TEL. NO.s`)S�`ISS
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.
Lender's Address
STATE LIC.
I certify that I have read this application and state that the LICENSE NO. CLASS
above information is correct. I agree to comply with all County
QPod1nances a tate laws relating to building construction,
d hern a v entjgn d property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date