HomeMy Public PortalAbout9719 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, HEATING - VENTILATING - AIR CONDITIONING
or a certified co y thereof(Sec. 3800, Lab. C.) 76A364C
u 3- ;a CE-818(REV. 10/81)
Policy No. 7—Company %JA C trn
Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AN S FETY
D
KJ Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING
tion department. (PRINT OR TYPE ONLY) ADDRESS '
�fLOCALITY C,
Date f-.7 - / Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST. C
(This section need not be completed If the work involved by ABSORPTION UNIT,BTU DISTRICT NO. PROOtSSED BY
the permit is for,one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM 4
I certify that in the perfotmance 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 INSPE OR'S SIGNATURE
Date Applicant COMPRESSOR,'BTU '4 a ROUGH
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 VALIDATI N
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU
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. IL
License Number 2-32 In ` a Lic. Class C 0 Q ,
rg
Contractor �-�ILAW to 1'—'s ;2 6 2 7.2 A
❑ I am exempt under ec. # 0 0 0 0 0 $ U
Plan check fee IL
h
B.BP.C. for this reason' PERMIT ISSUING FEE$ .1 0 a 4 a 0 0 �
Date: TOTAL FEE 0 0048,00M
Signature
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT 0 1, 0 Jr,-S 7
1 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 CITY TEL. NO:
the structure is not intended or offered for sale(Section
7044, Business and Professions Code).
OWNER � J 0 .
❑ 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 - CONTRACTORrQ� 0 1 poll(Sec. 3097, Civ. C.).
ADDRESS
Lender's Name '
CITY
TEL..
Lender's Address ^-
TATE LIC.
I certify that I have read this application and state that the SENSE NO. 5P 3910 I' CLASS C d
above information is correct. I agree to comply with all County
ordinances and State laws relating to building construction,
anc, hereby authorize representatives of this County to enter
u n the Above mentioned property for inspection purposes. SEE REVERSE FOR'EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date