HomeMy Public PortalAbout5566 WELLAND AVE_Mechanical__ ` WORKERS'COMPENSATION DECLARATION
iI hereby affirm that I have a certificate of consent to self' APPLICATION FOR PERMIT
°ensure, or a certificate of Workers'Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof (Sec. 3800, Lab. C.) CE-81 C
6�._TN9 I� ^1` vim— CE-818(REV. 10/81)
Policy No. 1��= ompany• i'n. 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. ADDRESS SS�a6
� (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. PROCESSED BY
the permit Is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM D
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws. BOILER, BTU APPROVALS DATE INSP OJA SIGNATu
Date Applicant COMPRESSOR,BTU ROUGH ``
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL
Exemption, you should become subject'to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDA N
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU GRAM
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED—UNIT—
'(commencing
USPENDED UNIT'(commencing with Section 7000)of Division 3 of the Business - WALL
and Professions Code;and my license is in full force and effect. A.
License Number qn 6os Lic. Class ® 40
CA
� I 11:3m( )
� �
Contractor`�, �/ C Date z 8 4 4 2 A 0
t—
❑ I am exempt under Sec. #r o,0 a a a 8 ILU
Plan check fee IL
N
B.BP.C. for this reason' �+
Date:
PERMIT ISSUING FEE$ r I a - .30.50
TOTAL FEE a a 3 C 5 0�
Signature
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT CC_ �'a/� I 1,30-87
1 hereby affirm that I am exempt from the Contractor's License V
Law for the following reason (Section 7031.5, Business and NAME
Professions Code):
❑ I, as owner of the property, or my employees with ADDRESSS
wages as their sole compensation,will do the work and CITY ^ C TEL. NO. o
the structure is not intended or offered for sale Section � _) S
7044, Business and Professions Code). C
- OWNER
❑ I, as owner of the property, am exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRES
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY ' CITY e— TEL. NO.J —
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
Zrd1nancesand State laws relating herby. uth riz representativn the`arbove- tinned roperty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
V r.
Signature of Applicant or Agent Date