HomeMy Public PortalAbout5564 WELLAND AVE_Mechanical__ ` WORKERS'COMPENSATION DECLARATION 4nAPPLICATION FOR PERMIT
I hereby affirm that I have a certificate of consent to self
' sure, or a certificate of Workers'Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof(Sec. 3800, Lob. C.) 76A364C
�-�'� CE-818(REV. 10/81)
Policy No:��_Corrpany\ JTQ�o-- 1�1 �
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. (PRINT OR TYPE ONLY) ADDRESS `1 yV
Date Applicant
LOCALITY �'
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS S7. ht
(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
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 INSP R'S SIGNATUBP
Date Applicant 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 ALIDA ON
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU
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. 0
License Number x160� Lic. Class_ ® %PContractor Date
z'8440A o
U
I am exempt under Sec. to'aaa �
Plan check fee e a 3 Q o8 5 0 v'
B.BP.C. for this reason' #A
Date:
PERMIT ISSUING FEE $ 00.030.5050
'
7 1
Signature TOTAL FEE 2,A S
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT 1'3 _8 7
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 S l` Z—
wages as their sole compensation,will do the work andCITY C`t- TEL. NO.'S--)'S
the structure is not intended or offered for sale(Section
7044, Business and Professions Code). OWNER r
❑ 1, as owner of the property,am exclusively contracting co �-
with licensed contractors to construct the project (Sec- MAIL f ^i �J
VV
tion 7044, Business and Professions Code). ADDRESS 1 1 Lrt
CONSTRUCTION LENDING AGENCY CITY IZ C_` TEL. NO.'5-)s) q
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
rdinonces and State laws relating to building construction,
nd hereby horize representatives of this County to enter
upo the -mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Il
Signature of Applicant or Agent Date