HomeMy Public PortalAbout9707 WINDSOR LN_Mechanical__ ,tom - WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
I 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 cop thereof(Sec. 3800, Lab. C.) 76A364C
)�; }^ CE-818(REV. 10/81)
0cY a Company—An( /Ylt-rllS
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
T- tion department. (PRINT OR TYPE ONLY) ADDRESS D
Date L-57- 3 Applicant - NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY
CERTIFICATE OF"EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS S
ABSORPTION UNIT,BTU DISTRICT NO. PROC D Y
(This section need not be completed if the work involved 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 BOILERBTU
so as to become subject to the Workers ,Compensation Laws. APPROVALS DATE I SP TOR'S SIGNATURE
Date Applicant �. COMPRESSOR,BTU L ! ROUGH J
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. FURNACE: FAU4 GR IT /
LICENSED CONTRACTORS DECLARATION FLOOR BTU I iG)v L
I hereby affirm that I am licensed under provisions of Chapter 9HEATER: 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. J
� 2�k-o u
License Number �� I Lic. Class
L U U C
Contractor . L t' kbate-
- D 7 0
❑ �626,9A L
I am exempt and r Sec.
Plan check fee - IL
B.&P.C. for this reason' #,0 0 0 0 0 $ �
Date: PERMIT ISSUING FEE$ ( o 0 4 8.Q Q
Signature TOTAL FEE o o,e =
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT 4 Q"
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and NAME N0111. 1.0 5:-8 7
Professions Code):
❑ 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).
❑ I, as owner of the property,am exclusively contracting OWNER 1 /1{ Pelxn4 ( e,
with licensed contractors to construct the project (Sec- MAIL
tion 7044, Business and Professions Code). ADDRESS
CONSTRUCTION LENDING AGENCY CITY TEL. NO.
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued CONTRACTORT
(Sec. 3097, Civ. C.).
ADDRESS -� / =1' I-) VNI
Lender's Name
Lender's Address � `
CITY r ' TEL. NO.
'
plication and state that the STATE LIC.
I certify that I have read this application LICENSE NO. ,A 3-a LU I CLASS
above information is correct. I agree to comply with all County
ordinances and State laws relating to building construction,
an hereby authorize representatives of this County to enter
,up the bove-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Dote