HomeMy Public PortalAbout9823 WOODRUFF AVE_Mechanical__ I
WORKERS'COMPENSATION DECLARATION APPLICATION I FOR PERMIT
1•httiieb"y df�irm that I have a certificate of consent to self
insure, or a certificate of Workers'Compensation Insurance; HEATING - VENTILATING - AIR CONDITIONING
or a certified cop theregf�Sec. 3600, b. C.) 76A364C
jjJ /� r ` CE-818(REV. 10/81)
Policy No.�Company R _T
❑ Certified copy is hereby furnished. ICOUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is'filed with the county building inspec FOR APPLICANT TO FILL IN BUILDING �� r JvO�� n
tion depftment. _ (PRINT OR TYPE ONLY) ADDRESS IJ T
Date .2—e6 Applicant i"° � LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE y
CERTIFICATE OF EXEMPTION FROM WOR ERS' NEAREST
COMPENSATION INSURANCE CROSS ST.
(This section need not be completed if the work Involved by ABSORPTION UNIT, BTU DISTRICT NO. PROCESSED BY
the permit is for one hundred dollars($100)or less.) I — v
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM t
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws. BOILER,BTU APPROVALS DATE INSPECTOR'S SIGN URE
Date Applicant I COMPRESSOR,BTU Q, ROUGH
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth-' EVAPORATIVE COOLER VALIDATION
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU sl G TY
LICENSED CONTRACTORS DECLARATION ftV r
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
(commencing with Section 7000)of Division 3 of the Business j WALL
and Professions Code,and my license is in full force and effect.'
License Number;2149;. 7 Lic. Class�--l24 ► U
r t?1
Contractor 5,L• A1404 Date
0
❑ I am exempt under tec.
Plan check fee CL
ta.
B.BP.C:for this reason' rA
PERMIT ISSUING FEE$ Q Z
Date:• TOTAL FEE 130, z 3 9 1..7 A
Signature
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT # o a o 0.0 8
1 hereby affirm that I am exempt from the Contractor's License ® I a a 3 a 5 0
Law for the following reason (Section 7031.5, Business and ' NAME
Professions Code):
❑ I, as owner of the property, or my employees with I ADDRESS a a o 3 Q 5 0
wages as their sole compensation,will do the work and CITY TEL. NO. ' 0 1,2 4-8 6
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 q Wo.94 'V•
tion 7044, Business and Professions Code). I
CONSTRUCTION LENDING AGENCY CITY j TEL. NO. (F
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued CONTRACTOR r
(Sec. 3097, Civ. C.). i a
ADDRESS 14 VI� C I I -4 .,a
Lender's Name
Lender's Address CITY 1VU S TEL. NO 6f8 jF 1(7
I STATE LIC.
I certify that I have read this application and state that the LICENSE NO. CLASS '
above information is correct. kagree to comply with all County I p
ordinances and State laws relating to building construction, p G� 4��� �lsi5ilP�Fj t–•iJ 207
and hereby authorize representatives of this County to enter '
upo �above-mentionecl property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature Applicant or.Agent Date