HomeMy Public PortalAbout9715 WINDSOR LN_Mechanical__ ',., 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, 76A964C HEATING - VENTILATING - AIR CONDITIONING
or a certified co thereof(Sec. 3800�ALab. C.) CE-818(REV. 10/81)
PolicyNo.03 040?5Company4.1�C ���t
❑ 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 BUILDINGC'�/�
Tion department. � ADDRESS(PRINT OR TYPE ONLY) �^
Date 0-7-Applicant �ul LOCALITY G
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST IF
COMPENSATION INSURANCE CROSS ST
(This section need not be completed if the work Involved by ABSORPTION UNIT,BTU DISTRICT NO. PRO
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
so as to become subject to the Workers'Compensation Laws. BOILER,BTU APPROVALS DATE IN7CTob SIGNATU E
Date Applicant COMPRESSOR,BTU 44 7G01 ROUGH - am
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 F LIDA ION
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU GRAVITY / jJ
LICENSED CONTRACTORS DECLARATION FLOOR
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. Pmln so a
License Number =�La:174 Lic.Class CID J f L, 2 6 2 7. � A
r .-�-�� � # aaaa ° g �
Contractor"111 F LiiL /�tf; `ate 1 ' 7 I o 0 4 $ 0.0 V
❑ I am exempt unde`f Sec.
Plan check fee ° ° It a 0 0 Ei 9L
B.BP.C. for this reason' U)
Date: PERMIT ISSUING FEE$ 0 1.05-87
Signature
TOTAL FEE
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 CIN TEL. NO.
7044, Business and Professions Code). t
OWNER
❑ I, as owner of the property, am exclusively contracting
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 CONTRACTOR n
(Sec. 3097, Civ. C.).
ADDRESS Z
Lender's Name
CITY�� ` 7 TEL. NO. $ ;5bLender's Address
STATE LIC.
I certify that I have read this application and state that the LICENSE NO. CLASS C c�
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
uR8 the/p� b�ovq�mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date