HomeMy Public PortalAbout9718 WINDSOR LN_Mechanical__ WORKERS'COMPENSATION DECLARATION 1 1 b/ /�
I hereby affirm that I have a certificate of consent to self APPLICATION FOR PERMIT
insure, or a certificate of Workers'Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
or a certified cop thereof(Sec. 3800, Lab. C.) 76A364C-
VJ S3 978 CE-818(REV. 10/81)
Policy No. Company Certified copy is hereby furnisheed.d. YtCC.% COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING
tion department. ADDRESS
(PRINT OR TYPE ONLY)
Date 5 9-7 Applicant I LOCALITY
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. r/ PROCE 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 �• ✓ 1111
permit is issued, I shall not employ any person in any manner BOILER,BT.0
so as to become subject to the Workers'Compensation Laws. APPROVALS DATE IN ECTOR•S s ATURE
Date Applicant COMPRESSOR, BTU ROUGH
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL r.
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: FAU GRAVITY q O
LICENSED CONTRACTORS DECLARATION FLOOR BTU '70, u
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
Contractor ►'i A-bate, i-s -97 O
❑ I am exempt undd Sec. f
Plan check fee
e.&P.C. for this reason PERMIT ISSUING FEE$ Z .
' Date:
Signature TOTAL FEE yLl® . ;262&5A
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License , #.000088
Law for the following reason (Section 7031.5, Business and NAME ;) o o [GaOO
Professions Code):
❑ I, as owner of the property, or my employees with ADDRESS o 0 0 4 8.O 05
wages as their sole compensation,will do the work and CITY TEL. NO.
the structure is not intended or offered for sole(Section 0 1, 05=8 7
7044, Business and Professions Code).
ElfOWNER 1 1- _ CIO
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
(Sec. 3097, Civ. C.).
ADDRESSC
Lender's Name
CITYUA 1AV TEL. NO. g -t �
Lender's Address .
STATE LIC.
I certify that I have read this application and state that the LICENSE NO. y' , 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
upon ab ve-m ntioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date