HomeMy Public PortalAbout9174 JAYLEE DR_HVAC_8/28/1984_furnace WORKERS'COMPENSATION DECLARATION 'CEA 8 8 12-80) Al If-.IF LL= ,CAT I O`II V FOR IL�t Ir"E R IMI � II
I. hereby affirm that I have a cettificate of consent to self "f .
insure,or a certificate of Workers,Compensation Insurance,or HEATING,VENTILAYIRIG-AIR CONDITIONING
a,certified couy thereof(Sec.3800,Lab.C.) ,..
o.
Policy rtified copy is hereby furnished.-• Compan
Certified
COUNTY OF LOS ANGELES BUILDING ARID SAFETY
Certified copy is filed with the county building inspection BUILDING /
department. FOR.APPLICANT TO FILL.IN gDpREss L:� y�� 1.
Date Applicant (PRINT OR TYPE ONLY)
LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE �� f
COMPENSATION INSURANCE NEAREST }
(This section.need not be completed if the work involved ABSORPTION UNIT, BTU CROSS ST. 0
by the permit i5 for one,hundred dollars.($100)nor less.) DISTRICT 1\10: PROCESSED V
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM i^ ` cc-
permit is issued,.I shall not employ any personon any manner 0
so as to become subject to the Work ers'•Compensation Laws. BOILER, BTU
- DA &�TR•ss W
APPROVALS TE' IGNATUREDate ApplicantCOMPRESSOR, BTU ROUGH Z
NOTICE TO APPLICANT: If, after makin this Certificate of /Q g VENTILATI.ON SYSTEM FINALExemptian., you should become subject to the Workers' -
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE VALIDATION.
with comply with such provisions' or this permit shall be
deemed revoked.
FURNP:CE: F A U CC AV1TY
LICENSED CONTRACTORS DECLARATION FLOOR: BTU� �- �—
I hereby affirm that I am licensed under provisions of Chapter HEATER: SUSPENDED UNIT
9. (commencing with Section 7000)of Division 3 of the Busi- .,WALL.
ness-and Professions Code,and my license is in full force and
effect.
License Number Lic;Class
Contractor Date
I am exempt from the licensing'requirements as I am.a
licensed architect or a registered professional engineer Plan Check fee 25%Of above.
acting in my professional capacity (Section 7051, Bus- PERMIT ISSUING FEE$
mess and Professions-Code).
Lic.or Reg.No. " Date r. TOTAL FEE
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT (�
I hereby affirm that I am exempt from- the Contractor's NAMES q. _� \
License Law for the following reason (Section 703,1.5,,Busi- 3$nJ •3,'2 A
ness and Professions.Code): ADDRESS
/ _ J am' \�(J #.opo ota il'$'
I as owner of the property, will do the work and the l r-d _
(�� ioro :3 l5 o
structure is not intended or, offered for sale (Section f „
7044, Business and Professions.Code). ° , =
OWNER / . 0,0 3 0 5 Q° v.'
I; as owner of the property, am exclusively contracting
with licensed coutractors to construct She project MAILO 8. 2 8-84
(Section 7044, Business and Professions Code). ADDRESS -�� _�Qt � LJ 1 • r
CONSTRUCTION LENDING AGENCY CITY TEL.NO.
I hereby affirm that there is a construction'lending agency CONTRACTOR—-' for the performance of the work for which this permit is '
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 upon the above-mentioned property for
I
lltiol^purposes.
I
Permute Date