HomeMy Public PortalAbout9015 ACASO DR_Mechanical_10/29/1981_furnance WORKERS'COMPENSATION DECLARATION CEA$$ (2 -80) G lf� L��C QT �I If USS 1� RMT
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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
a certified copy thereof(Sec. 3800,Lab.C.)
Policy Noy, Company COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is hereby furnished.
Certified copy is filed with the county building inspection FOR APPLICANT TO FILL ON BUILDING
department.
Date Applicant (PRINT OR TYPE ONLY) ADDRESS �
LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
COMPENSATION INSURANCE NEAREST
CROSS ST. AS d
(This section need not be completed if the work involved ABSORPTION UNIT, BTU �A ® �� � N� p
by the permit is for one hundred dollars ($100) or less.) - DISTRICT NO. PROCESSED By C)
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 anyman x DDUU(( Lis O
so as to become subject to the ' rkers' en, n L, BOILER, BTU'
APPROVALS DATE INSPECTOR'S SIGNATURE IU
Date Applicant_ COMPRESSOR,BTU ROUGH N
NOTICE TO APPLICANT: If, after making th rtificate of - VENTILATION SYSTEM Z
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.
FURNACE: FAUGRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU f�eaC
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- WALL
ness and Professions Code, and my license is in full force and
effect.
License Number Lie.Class
Contractor Date
I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer Plan check fee 25%of above.
acting in my professional capacity (Section 7051, Bus- D0
iness and Professions Code). PERMIT ISSUING PEE $
Lie,or Reg.No. Date TOTAL FEE l 7 ®e7
HOME OWNER-BUILDER DECLARATION. PLAN CHECK APPLICANT
I hereby affirm that I am exempt from- the Contractor's NAME
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): ADDRESS
X1 I, as owner of the property, will do the work and the 1 7 S 1 A
structure is not intended or offered for sale (Section CITY TEL. NO.
7044, Business and Professions Code). / # 0 0,0 0 0 8*
aOWNER IF 0 A&0(i Q +, ,
I, as owner of the property, am exclusively contracting _ '2 0,0 1 i7 0 0
SAwith licensed contractors to construct the project' MAI L t` ,n
(Section 7044, Business and Professions Code). ADDRESS o.0 0 13,Q 0',
CONSTRUCTION LENDING AGENCY CITY TEL. NO.
I hereby affirm that there is a construction lending agency i 0,2 9—8 1'
for the performance of the work for which this permit is CONTRACTOR
issued(Sec. 3097,Civ.C.).
Lender's Name ADDRESS
Lender's Address CITY TEL.NO.
I certify that I have read this application and state that the STATE LIC.
above information is correct.I agree to comply with all County LICENSE NO. CLASS
ordinances and State laws regulating Heating, Ventilating and
Air Conditioning, and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
County to enter t6 the ,,ve-men lone p perty for
tion pur S.
Sig ture 0 ermittee Date