HomeMy Public PortalAbout9708 WINDSOR LN_Mechanical__ U1S'COMPENSATION DECLARATION APPLICATION FOR PERMIT
� I kereliy affirmffirm 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. 3800 Lab. C.) 76A364C
(�,'�5a 3�fGQc� CE-818(REV. 10/81)
Policy
c cert Company s ed. r'J1t 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. (PRINT OR TYPE ONLY) ADDRESS 7O
Date r— -9 7 Applicant '_^ t?.1/ �t� LOCALITY G
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. PR SE B
the permit is for one hundred dollars($100)or less.) o
AIR HANDLING UNIT,CFM '
I certify that in the performance of the work for which this [
permit is-issued, I shall not employ any person in any manner BOILER,BTU
so.as to become subject to the Workers'Compensation Laws. APPROVALS DATE INSP CT 'S SIGNATURE
Date Applicant `�
f COMPRESSOR, BTU t` '6 ROUGH -
i w
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you rhUst forth- EVAPORATIVE COOLER VALIDATION
with.comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU G��gqVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU '7ci.G�l�C3
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT—. ) J(
'(commencing with Section.7000)of Division 3 of the Business WALL ` (f
and Professions Code,and my license is in full force and effect.
License Number �� 0 f a Lic. Class C2 U
Contractor Date 1'7-%3-7 O
o°
❑ /
I am exempt under ec.
Plan check fee CL
B.BP.C. for this reason' 2-6268A
PERMIT ISSUING FEE$
Date: # 0 0 0 0 0
Signature -TOTAL FEE
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT ( o o [� Q Q
I hereby affirm that I am exempt from the Contractor's License ® e o o 4 a 0 0 5
Law for the following reason (Section 7031.5, Business and NAME
Professions Code):
El 1, as owner of the property, or my employees with ADDRESS 1,05-87
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
OWNER a i
El . �; ( Clot G
MAIL I, as owner of the property, am exclusively contracting - _- -
with licensed contractors to construct the project (Sec- MAILS
tion 7044, Business and Professions Code):
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 CONTRACTOR f�
(Sec. 3Q97, Civ. C.). (• �.. l.( '� ' l
• ADDRESS
Lender's Name I r!%i-._J 1 \ [<<�
LSTATE
L'Y (� � / TEL. NO. 7 '
Lender's Address r
LIC.
qq
I certify that I have read this application and state that the O. eQ 3,�j CLASS
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
upt e a ove entioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
a If _9&n !- - S'2
Signature of Applicant or Agent Date