HomeMy Public PortalAbout9421 WOODRUFF AVE_Mechanical__ .i-. ,
WORKERS'COMPENSATION DECLARATION APPLIC�4TION ®R PERMIT
'1 hert�affirnl that I have a certificate of consent to self
I,
sure, or a certificate of Workers'Compensation Insurance, 76Aa�c HEATING - VENTILATING - AIR CONDITIONING
ror a certified copy thereof(Sec. 3800, Lab. C.) CE-818(REV. 10/81)
Policy No. Company
Certified copy is hereby furnished. 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 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. PROCESSED BY
AIR HANDLING UNIT,CFM
the permit is for one hundred dollars($100)or less.) {i Y
I certify that in the performance of the work for which this
lJ
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws. BOILER,BTU APPROVALS DATE INSP CTOR' IGNATURE
C67
Dat
`! Y7 pplicant COMPRESSOR,BTU ROUGH
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL %
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU G AVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
'(commencing with Section 7000) of Division 3 of the Business WALL =,
and Professions Code,and my license is in full force and effect.
License Num 329�/;Z=_Lic. Class � � l (/ V ® III
Co te 11—
I am exempt unTer Sec. 0,7720A V
Plan check fee IL
up
B.BP.C. for this reason' # 0 0 0 0 0 8
PERMIT ISSUING FEE$
Date: .1 a s 41,0 0
Signature TOTAL FEE
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT o a - 41.00'
1 hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and NAME Poo. G$,2 1 87
Professions Code):
El1, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and
the structure is not intended or offered for sale(Section CITY TEL. NO.
7044, Business and Professions Code). OWNER
IL
❑ 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 L. NO.
I hereby affirm that there is a construction lending agency for 01
the performance of the.work for which this permit is issued CONTRACTOR
(Sec. 3097, Civ. C.).
ADDRESS
Lender's Name
Lender's Address C.CITY TEL. �qee-:�p
i
I certifythat I have read this application and state that the AT LIC.
pp LICENSE NO. CLASS 2-D
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 t bove-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
-z�;
Signa ure of'Applicant or Agent Date