HomeMy Public PortalAbout9716 WOOLLEY ST_Mechanical__ WORKERS'COMPENSATION DECLARATION ; APPLICATION FOR PERMITell
I hereby affirm that I have a certificate of consent to self,
*insure, or a certificatesof Workers'Ccfmpensation Insurance HEATING - VENTILATING - AIR CONDITIONING
}or a certifieZIopy thereof:(SY:c. 3800, Lab. C.) I 76A364C
CE-818(REV. 10/81)
Policy No. Company
Certified copy is hereby furnished. I COUNTY OF LOS ANGELES BUILDING AND SAFETY
❑' Certified copy is filed with the county building inspec-I FOR APPLICANT TO FILL IN BUILDING
tionplepartment. ADDRESS
_ (PRINT OR TYPE ONLY)
Date Z - �� S y Applicant 14Z� 1 Z' LOCALITY ,�. � -,
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST n \
COMPENSATION INSURANCE CROSS ST. t\�_
(This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO. CESSED BY
the permit Is for one hundred dollars($100)or less.)
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM J•O PRO
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers ) BOILER,BTU Compensation Laws. APPROVALS DATE INSfECTOY SIGNATURE
Date Applicant ' COMPRESSOR, BTU Y il,� (J ✓ ROUGH
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATI N
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU G fyVITY
LICENSED CONTRACTORS DECLARATION FLOOR (! LI
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT'(commencing with Section 7000)of Division 3 of the Business WALL '
and Professions Code,and my license is in full force and effect.
License Number t �ti Lic.Class-��
Contractor Date
❑ U
I am exempt under Sec. sou
Plan check fee H
B.&P.C. for this reason I PERMIT ISSUING FEE$
Date:
Signature TOTAL FEE
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT 2 6 6 2 8 A
I hereby affirm that I am exempt from the Contractor's License ,
Law for the following reason (Section 7031.5, Business and NAME o 0 0 0 0 8
Professions Code):
❑ I, as owner of the property, or my employees with
ADDRESS I o - 4625
wages as their sole compensation,will do the work and CITY TEL. NO.
the structure is not intended or offered for sale(Section o 0 - 46255
7044, Business and Professions Code).
OWNER
❑ I, as owner of the property, am exclusively contracting _ 0 a 0 5=8 7
with licensed contractors to construct the project (Sec- MAIL
ADDRESS
tion 7044, Business and Professions Code). _
CONSTRUCTION LENDING AGENCY CITY ,7j; r/xi,` "; _ TEL. NO.
1 hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued CONTRACTOR .:-, � ��f
(Sec. 3097, Civ. C.).
Lender's Name ADDRESS ' �' �'•"
CITYqq TEL. NO.
Lender's Address f`'I�r ;ic.J. : '1
STATE c-cz, )'-I — LIC.
I certify that I have read this application and state that the LICENSE NO. c. z;, CLASS 1
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
upq the abo entloned property for inspection purposes. j SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date