HomeMy Public PortalAbout4903 ARDSLEY DR_Mechanical__ WORKERS'COMPENSATION DECLARATION CEA g64g
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I hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers'Compensation Insurance,or H El°�706�G_MCF9'4 ILATING- IR CONDMOM11MG
��c/ryyVied co/py t �eo(�,Jf(Sec. 3800,Lab C.)
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COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is hereby furnished.
Certified copy is filed with the county building insnPction �— — ®4R APPLICANT�� FILL 9fZ! [
BUILDING
d /�
ar Hent. t ADDRESS 1 a
Date 4 pplicant_� (PRINT OR TYPE ONLY)
LOCALITY /T�
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE 0
COMPENSATION INSURANCE NEAREST }
(This section need not be completed if the work involved ABSORPTION UNIT, BTU CROSS ST. a0
by the permit is for one hundred dollars ($100) or less.) DISTRICT NO. PROC s av V
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM 51dy
permit is issued, I shall not employ any person in any manner O
so as to become subject to the Workers' Compensation Laws. BOILER, BTU
000
O Q APPROVALS DATE INS EC R'S SIGNATUR IU
Date Applicant f COMPRESSOR, BTU ' ROUGH C
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM
Exemption, you should become subject to the Workers' FINAL �.
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION
with comply with such provisions or this permit shall be
deemed revoked. / r; AVITY /Ov
FURNACE: FAU [
LICENSED CONTRACTORS DECLARATION FLOOR: BTU__ _�—U4 c�—
I hereby affirm that I am licensed under provisions of Chapter HEATER: SUSPENDED UNIT
9 (commencing with Section 7000) of Division 3 of the Busi- I) WALL
ness and Professions Code, and my license is in full force and
effect.
License Number ✓> Lic.Class C �I
Contractor
CO3A1/1dR Date_&4A_-I?e j
ElI am exempt from the licensing requirements as I am a r
licensed architect or a registered professional engineer Plan check fee 25%of above.
acting in my professional capacity (Section 7051, Bus- —
iness and Professions Code). II PERWT ISSUING FEE $
Lic.or Reg-No. Date T®TAL FEE 2 4 7 6 0 A
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
1 hereby affirm that I am exempt from- the Contractor's NAME
License Law for the following reason (Section 7031.5, Busi- ' ! 3(1 5 0
ness and Professions Code): ADDRESS
1, as owner of the property, will do the work and the • • ! 3(1500
T;
structure is not intended or offered for sale (Section CITY TEL. NO.
7044,Business and Professions Code). OWNERa,� / 6,0 3� 8 b
Al A
, ///✓� �
I, as owner of the property, am exclusively contracting
with licensed contractors construct the project I ADDRESS
(Section 7044, Pr.Business and Professions Code). I
CONSTRUCTION LENDING AGENCY CITY T TEL.NO2. gt 372
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is CONTRACTOR :
issued(Se . 3097,Civ.C.). ��/�/�/d ��C:
Lender's Name ADDRESS
Lender's Address �SCLTICXENSE
Y TEL.NO.(�y/f a y3
I certify that I have read this application and state that the TE (��� �S LIC.
above information is correct.I agree to comply with all County NO. t CLASS 5
ordinances and State laws regulating Heating, Ventilating and
Air Conditioning, and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
County to enter upon the above-mentioned proverty for
inspectj9,n
Signature of Permittee Date