HomeMy Public PortalAbout9711 WINDSOR LN_Mechanical__ WORKERS'COMPENSATION DECLARATION
APPLICATION FOR PERMIT
w,"--I here6y affirm that I have a certificate of consent to self
insure, or a certificate of Workers'Compensation Insurance, HEATING - VENTILATING - AIS CONDITIONING
or a certified cop x thereof(Sec. 3800, Lab. C.) 76A364C
al 5 a 5'J %6) CE-818(REV. 10/81)
Policy No.-Co mpany �JLS!lY�l r:7U
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 Z71Z
tion department. ADDRESS
_ , (PRINT OR TYPE,ONLY)
Date Z ' j -7 Applicant ^ L�- 1. LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE v
CERTIFICATE OF EXEMPTION FROM WORKERS' I NEAREST
COMPENSATION INSURANCE CROSS ST
(This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO. POVISED BY
the permit is for one hundred dollars($100)or less.)
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws. BOILER, BTU APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant COMPRESSOR,BTU UV ROUGH _214 Iii TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDAT N
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU GRAVITY _
LICENSED CONTRACTORS DECLARATION J FLOOR BTU Ct r->V 1066
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT'(commencing with Section 7000)of Division 3 of the Business I WALL
and Professions Code,and my license is in full force and effect. LL �f
U(-
License Number (a Lic. Class (ID6 %P
Contractor •� ����✓� Date — - S� -2 z 6 2 7, A O
El
0 0 0 0 8 Ili
I am exempt unde Sec. w
Plan check feel a a 4$ 0 0 CL
B.BP.C. for this reason* PERMIT ISSUING FEE$ �
Date: ;a 0 0 4$,C o m
Signature TOTAL FEE 5 8 7
i
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
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
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 J ./)L
E:] I, as owner of the property,am exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRESS
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
(Sec. 3097, Civ. C.). �^• 'LVL A Pool
ADDRESS 061 ! tCq ;1 ell
Lender's Name � '`� �-^-'`-•"
CI ( �3 lT TEL. NO. .)&!5-��
Lender's Address
STATE LIC.
I certify that I have read this application and state that the LICENSE NO. , �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
up P he above- entionpd property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
P
Signature of Applicant or Agent Date