HomeMy Public PortalAbout10919 WILDFLOWER RD_Mechanical__ i
WORKERS',COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self, APPLICATION OOR PERMIT
insure, or a certificate of Workers'Compensation Insurance, HEATING - VENTILATING -, AIR CONDITIONING
or a certified copy thereof(Sec. 3800, Lab. ) CE-81 C
CE-818(REV. 10/81)
Poli F7 � - Company
Certified copy is hereby furnished. COUNTY OF LOS ANGELES ` / : BUILDING AND SAFETY
2 Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING ,,'' oo ! l+
tion department. ADDRESS �� r t LV 1�(D�1&I f2-
c' (PRINT OR TYPE ONLY) W
Date Z "'a Applicant &A at-05 rnSOYIIi- LOCALITY P�f r P �i7'
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST. Wy j5 Z/LA ^;
(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($100)or less.)
AIR HANDLING UNIT,CFM
I certify that in the performance of the work for which this � (JJ
permit is issued,I shall not employ any person in any manner
so as to-become subject to the Workers'Compensation Laws. BOILER,BTU APPROVALS DAT INSPECTOR'S SIGNATURE
Date �— Applicant COMPRESSOR,BTU ROUGH
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL15V_Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- I EVAPORATIVE COOLER ALIDATI ' N
with comply with such provisions or this permit shall be ��
deemed revoked. FURNACE: FAU CaRAWY
LICENSED CONTRACTORS DECLARATION FLOOR BTU 20.DSO
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
'(commencing with Section 7000) of Division 3 of the Business - WALL
and Professions Code,and my license is in full force and effect.
License Number Lic.Class_F2 ® %P
Contractor�,,�,
/�A11/,65 %aio Date 'G' 0
❑ I am exempt under Sec. UJ
Plan check fee N
B.&P.C. for this reason'
PERMIT ISSUING FEE$ O
Date: 6 1.,8 A
Signature•- 8TOTAL FEE (} �
0 0 0 0 0
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT 2 G,'5 0
I hereby affirm that I am exempt from the Contractor's License I ® `
Law for the following reason (Section 7031.5, Business and NAME o'0020.506
Professions Code): i
❑ I, as owner of the property, or my employees with. Ilf ADDRESS 1,Q 7L-8 3
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 eA2MC_LPJ
❑ I, as owner of the property,am,exclusively contracting
with licensed contractors to construct the project (Sec- MAIL ^
tion 7044, Business and Professions Code). i ADDRESS r 6 G D
M
CONSTRUCTION LENDING AGENCY CITY `O`er TEL. NO. 7- 3 S
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued CONTRACTORdv/4
(Sec. O S L� d
(Sec. 3097, Civ. C.). f_
loop
ADDRESS Z C Qu)z 7
Lender's Name /
Ava-
CITY TEL. NO. 44-7 -4-0
9'
Lender's Address
STATE LIC. }}��
I certify that I have read this application and state that the LICENSE NO. CLASS [j
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
upefi?he above-mention, tl property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date