HomeMy Public PortalAbout9722 WINDSOR LN_Mechanical__ t,-WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
I hereby affirmffirmthat I have a certificate of consent to self
insure, or a certificate of Workers'Compensation Insurance, HEATING - 'VENTILATING - AIR CONDITIONING
or a certified copy_th ooff(Sec. 3800, Lab. C.) 76A`364C
JS / CE-818(REV. 10/81)
Policy No. Company
Certified copy is hereby furnished..ed. IY — COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING
ftJ tion department. I (PRINT OR TYPE ONLY) ADDRESS
Date -o Applicant LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE -7 e5n
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. PROCEY
the permit is for one hundred dollars(;100)or less.) /)u
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM Q/U
permit is issued;I shall notemploy any person in any manner BOILER,BTU
so as to become subject to the Workers'Compensation Laws: ,) APPROVALS DATE INECTOR' IGNATURE
Date Applicant COMPRESSOR,BTU v 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 VALIDA I N
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU GRAVITY /fes
LICENSED CONTRACTORS DECLARATION FLOOR.:. BTU I hereby affirm that I am licensed under provisions of Chapter 9 �' SUSPENDED UNIT
'(commencing with Section 7000)of Division 3 of the Business HEATER: WALL
and Professions Code,and my license is in full force and effect. CL
License Number -�*rZ` �.a. Lic. Class 1 ► U
09
t �62b6A
Contractor' %7 ate /—6
I am exempt undrr Sec. #'0 0 0 0 0
.Plan check fee IL
:I a a 4 8 0 0 IL
B.&P.C. for this reason PERMIT ISSUING FEE$
Date: d - o 0 0 [j,a,O O v
Signature TOTAL FEE
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT 01,05-4-87
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 CITY TEL. NO.
the structure is not intended or offered for sale(Section
7044, Business and Professions Code).
OWNER Co
ElI, 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 ,
tAm
he performance of the work for which this permit is issued CONTRACTOR
(Sec. 3097, Civ. C.).
ADDRESS ,
Lender's Name ,
CITY TEL. NO.
Lender's Address '//STATE _� '
'I certify that I have read this application and state that the [LICENSE NO, aja IC;I o� CLASS Civ
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
uponh above-me tioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
AP
Signature of Applicant orAgent Date