HomeMy Public PortalAbout9157 WOOLLEY ST_Mechanical__ e WORKERS'ffCOMPENSATION DECLARATION APPLICATION FOR PERMIT
I he$eby a �•m that I have a certificate of consent to self �
{pure, Gra certificate of Workers'Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof(Sec. 3800, Lab. C.) 76A364C
SCE-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
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST. 45jc-i/tel T
(This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO. PROC
the permit is for one hundred dollars($100)or less.)
Qom% r
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM
permit is issued, I shall not employ any person in any manner
so as to become subject to the erS BOILER, BTU CO en5ation LOWS. APPROVALS DATE INS ECTOR'S SAATLIRE
-�,– COMPRESSOR,BTU /C/ ROUGHIt ge
Date pplicant �
ma
NOTICE TO APPLICANT: If, after king/thl Certificate VENTILATION SYSTEM FINAL
Exemption, you should become subjeckto the Workers_
Compensation provisions of the Labor Code,you must forth- EVAPORATIVE COOLER VALIDATI
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU AG VITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU O
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED—UNIT-
'(commencing
USPENDED UNIT'(commencing with Section 7000) of Division 3 of the Business WALL
and Professions Code,and my license is in full force and effect.
IL
O
License Number Lic. ClassA 09
V
!V
Contractor Date O
❑ I am exempt under Sec. U
Plan check fee H
8.8P.C. for this reason PERMIT ISSUING FEE$ 0
Date:
Signature TOTAL FEE
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License G
Law for the following reason (Section 7031.5, Business and NAME F5 6L Q i.(J 9)01N0 7— 00
Professions Code):
❑ �.I, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and CITY TEL. NO.
the structure is not intended or offered for sale(Section J('
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). t'5 9 1,2 A
CONSTRUCTION LENDING AGENCY CITY TEL. NO.
I hereby affirm that there is a construction lending agency for 0 0 0 0 0 $
the performance of the work for which this permit is issued CONTRACTOR
(Sec. 3097, Civ. C.). I o 0 41j,50
ADDRESS
Lender's Name 0 0 0 4 4,-,0,5
CITY TEL. NO.
Lender's Address11, 1 8 6
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
��igno
n the ab J-mentiy for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
a re of pplica
At o Agent Date