HomeMy Public PortalAbout9085 WOOLLEY ST_Mechanical__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
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
p y 6TE' ] CE-818(REV. 10/81)
Policy No. �Oa�� �om an �� �"JNet •
Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with the county building ihspec- FOR APPLICANT TO FILL IN BUILDING �; �j /�/
tion epart ent. � ADDRESS WooS
�/ (PRINT OR TYPE ONLY)
Date �e A Applicant�'"!' ' rpfVivi�l�d� NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY i� e— %y
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST. /L
(This section need not be completed if the work Involved by ABSORPTION UNIT, BTU• DISTRICT NO. PROC v
the permit is for one hundred dollars($100)or less.)
AIR HANDLING UNIT,CFM �� V
I certify that in the performance of the work for which this �
permit is issued, I shall not employ any person in any manner BOILER,BTU
so as to become subject to the Workers'Compensation Laws. �/.../ APPROVALS DATE INSP TOR'S SIGNATURE
Date Applicant COMPRESSOR,BTU?/�`C/coo / ���N 0 '� ROUGH -�3 I i
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALInATI N
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9 A HEATER: SUSPENDED UNIT C5 0-/
--
'(commencing with Section 7000) of Division 3 of the Business WALL
and Professions Code,and my license is in full force and effect.
License Number Lic. Class CT c�0 ® U
A4IIti-e I`ley}7. 0,c
Contractor +; P O �'� Date / A
❑ I am exempt under Sec. d
Plan check fee y
B.&P.C. for this reason PERMIT ISSUING FEE$ /O
D 6D
Signature)% /` �4' J_d/ - TOTAL FEE
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License
Law for the Yp(lowing reason (Section 7031.5, Business and NAME
Professions Co-ee):
ADDRESS
���
El I, as ownof the property, or my employees with
wages as ihe`i sole compensation,will do the work and CITY TEL. NO.
the structure is of intended or offered for sale(Section j{
7044, Business a d Professions Code). OWNER SSS C
❑ I, as owner of the kopqrty, am exclusively contracting
with licensed contra ors to construct the project (Sec- MAIL (i[�C�C 1�C}z T' ;20668A
tion 7044, Business an Professions Code). ADDRESS 6�''
CONSTRUCTION NDING AGENCY CITY ao[,¢ C_'i'T TEL. NO ' rj= f�
I hereby affirm that there is a co truction lending agency for # 0 0 0 o a 8
the performance.of the work for hich this permit is issued CONTRACTOR {r-4sS
� Ire; T /7
- 30,50
(Sec. 3097, Civ. C.). ADDRESS J�V
Lender's Name , J / 0 0 o30.50
v
CITY R ds FsTEL. NO. �—���' 0 9 1 4-88
Lender's Address _ i GSTATE �s
I certify that I have read this application and state that the LICENSE NO. ,�/ j� .S C ASS
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 thab e-meolled property for inspectionpurl oses. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agefi Date