HomeMy Public PortalAbout9727 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 copy thereof(Sec. 3800, Lab. C.) CE-81 C
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Certified copy is hereby furnished. cVti C'�►�-1 CE 818(REV. 10/81)
Policy I�oS '�I
Company - COUNTY OF LOS ANGELES BUILDING AND SAFETY
�( Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING '?7� 7
(PRINT OR TYPE ONLY)
tion department. ADDRESS !�v
Date I "5?-7 Applicant LOCALITY G
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. PROLE s
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 5L
permit is issued, I shall not employ any person in any manner BOILER,BTU
so as to become subject to the Workers'Compensation Laws. APPROVALS DATE INSPECT SIGNATURE
Date Applicant COMPRESSOR,BTU M 9PVU 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 VAI.IDATIO
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU�GV.44TY
LICENSED CONTRACTORS DECLARATION FLOOR
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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,arid my license is in full-force and effect. 911.
License Number 52101 .a Lic. Class !
a , V
Contractor U-Z-1 �,to i\ I I�dfe $ ' O /
❑ V
I am exempt under 9ec. lus
Plan check fee , IL
6.8P.C. for this reason' h
�b 2 7 4 A �+
. PERMIT ISSUING FEE$ m
'
Signature Date: '
TOTAL FEE 041 # d.00008
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT 10,o 4 8 Q O
Ihereby off irm that I am exempt from the Contractor's License.
Law for the following reason (Section 7031.5, Business and NAME , o -,- 4a00,0
Professions Code):
❑ I, as owner of the property, or my employees with ADDRESS 1,05"87
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 �
❑ 1,as owner of the property, am exclusively contracting t I
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 Pool
performance of the work for which this permit is issued CONTRACTOR
(Sec. 3097, Civ. C.).
ADDRESS _
Lender's Name p
CITY TEL. NO.. 8:_ g oq 9
Lender`s Address STATE , LIC.
I certify that I,have read this application and state•that the LICENSE NO. 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
uFu the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
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Signature of Applicant or Agent Date