HomeMy Public PortalAbout9723 WINDSOR LN_Mechanical__ din
I, 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 copy.thereof(Sec. 3800, Lab. C.) 76A364C
u)5 R 3RC9� CE-818,(REV. 10/81)
Policy No..Company
Company Fd.tSf�'YYt
Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with the county building inspect FOR APPLICANT TO FILL IN BUILDING?7
tion department.
(PRINT OR TYPE ONLY) ADDRESS
Date Applicant . LOCALITY., G
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS
(This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT N-.- PROC Y
the permit is for one hundred dollars($100)or less.)
AIR HANDLING UNIT,CFM
I certify that in the performance of the work for which this L
permit is issued, I shall not•employ any person•in any manner
so as to become subject to the Workers'Compensation Laws.. BOILER,BTU /� > APPROVALS DATE INSPECT &SIGNATURE
Date Applicant COMPRESSOR, BTUV 60 ROUGH.14 — Z
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDAT ON
with comply with such-provisions or this.,permit shall be
deemed revoked. FURNACE: FAU GR IY_�_ AA
LICENSED CONTRACTORS DECLARATION 6 FLOOR BTU 3
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
'(commencing with Section 7000)of Division 3 of the Business - WALL
and Professions Code,and my license is in full force
�and
�effect. /`
License Number r3o�(tsi.al Lic.ClassS�
Contracto ate 1'5 "?7. O
I am exempt uncltsec.
Plan check fee " y
B.&P.C. for this reason' 2 6 2 7 3 A Z
PERMIT ISSUING FEE$
Dater TOTAL FEE ## 0 0 0 0 0 8
• Signature � � '
OWNER-BUILDER DECLARATION - • . PLAN CHECK APPLICANT ;1 0'0 4 a O O
I hereby affirm that I am exempt from the Contractor's License , .0 0 - 4a005
Law for the following reason (Section 7031.5, Business and NAME '
Professions Code): ,
❑ I,, as owner of the property, or my.employees with ADDRESS 0 1.0 5j 8 7
wages as their sole compensation,will do the w&k and CITY TEL. NO.
the structure is not intended or offered for sale-(Section
7044; Business and Professions.Code).
OWNER
❑ 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 offiem that there Is-a construction lending agency for ,
the performance of the work for which this permit is issued CONTRACTOR _
(Sec..3097, Civ. C.).
ADDRESS
Lender's Name
CITY TEL. NO. • r7�+
Lender's Address
STATELIC.
I certify that I have read this,application and state that the LICENSE No. oZ�Jc��O� 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
ulft. the bov -med property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date