HomeMy WebLinkAbout6121AWORKERS' COMPENSATION DECLARATION
I hereby affirm Phot I have a certificate of consent to self
insure, or o certificate of Workers' Compensation insurance,
or a certified copy thereof (Sec. 3800, Lob. C. )
Policy No. Company
Certified copy is hereby furnished.
Certified copy is filed with the county building inspec-
tion department.
Date Applicant
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the work involved by
the permit is for one hundred dollars ($100) or less.)
I certify that in the performance of the work for which this
permit is issued, 1 sholl not employ any person in any manner
so as to become subject to the Workers' Compensotion Laws.
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth-
with comply with such provisions or this permit shall be
deemed revoked.
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I om licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business
and Professions Code, and my license is in full force and effect.
License Number Lic. Class
Contractor Date
❑ I am exempt under Sec.
BAP.C. for this reason
Date:
Signature
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason {Section 7031.5, Business and
Professions Code):
❑ I, as owner of the property, or my ernployees with
wages as their sole compensation, will do the work and
the structure is not intended or offered for sole (Section
7044, Business and Professions Cade).
❑ I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec-
tion 7044, Business and Professions Code).
.CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is Issued
(Sec, 3097, Civ. C.).
Lender's Nam
Lender's Address
I certify that I have read this application and state that the
above information is correct. I agree to comply with all County
ordinances and State laws relating to building consfruction,
and hereby authorize representatives of this County to enter
upon the above-mentioned property for inspection purposes.
Signature of Applicant or Agent Date
APPLICATION FOR PERMIT
76A364C HEATING - VENTILATING - AIR CONDITIONING
CE - 815 (REV_ 10/81 }.
COUNTY OF LOS ANGELES
BUILDING AND SAFETY
FOR APPLICANT TO FILL IN
(PRINT OR TYPE ONLY)
BUILDING
ADDRESS
LOCALITY
NO.
TYPE OF APPLIANCE OR EQUIPMENT
FEE
NEAREST
CROSS ST.
ABSORPTION UNIT, BTU
DISTRICT NO.
PROCESSED BY
AIR HANDLING UNIT, CFM
BOILER, BTU
APPROVALS
DATE INSPECTOR'S SIGNATURE
COMPRESSOR, BTU
ROUGH
VENTILATION SYSTEM
FINAL
EVAPORATIVE COOLER
VALIDATION
,
f
FURNACE: EAU GRAVITY
FLOOR BTU
HEATER: SUSPENDED UNIT
WALL
Plan check fee
PERMIT ISSUING FEE
TOTAL FEE
PLAN CHECK APPLICANT
NAME
ADDRESS
CITY TEL, NO.
OWNER
MAIL.
ADDRESS
CITY TEL. NO.
CONTRACTOR
ADDRESS
CITY TEL NO
STATELIC,
LICENSE NO CLASS
SEE REVERSE FOR EXPLANATORY LANGUAGE
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