HomeMy Public PortalAbout9445 LAS TUNAS DR_HVAC_7/27/1989_exhaust fan and duct work, outlets WORKERS'COMPENSATION DECLARATION C5 -8 1(2"6u) APPUCATION FOR
I hereby affirm that I_hsae. a certificate of consent to self �/G a' J�� /
insure,or a certificate of Workers'Compensation Insurance,or G�(E(QTINCs-dI�I�1TILATIWG-Alffd CONDITIONING
certified copy thereof(Sec. 8001 Lab.C.)
Policy No4l—c_=2i15m panA3ov� �
.N.Certified copy is-hereby furnished: COUNTY OF-LOS ANGELES BUILDING.AND SAFETY
Certified copy is.*filed with the county building inspection BUILDING
1
de rtm,nt t� _ FOR APPLICANT TO.FILL-IN ADDRESS Los Tu-rias
Date _ Applicant l'1_l2-ffn (4.111 (PRINT OR TYPE ONLY) �9
LOCALITY ��il'1�� ��i l
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
COMPENSATION.INSURANCE' NEAREST
CROSS ST.
(This section need not"be completed if the work involved ABSORPTION UNIT, BTU (L
by .the permit is for one hundred dollars (5100) or less.) DISTRICT NO. PROCESSED BY O
I certify that in the performance of the.work for which this JAIR HANDLING UNIT,CFM _ `O SKI
permit is issued, I shall not employ any person in any manner - � a f(I 0
so as to become subject"to the Workers' Compensation Laws.. BOILER, BTU
APPROVALS DATE. INSPECTOR'S:SIGNATURE V
Date Applicant COMPRESSOR,BTU lL
ROUGH d
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM U.
Exemption, . you should become subject to the Workers' FINAL Z'
Compensation provisions of the Labor-Code,you must forth-
with comply with.such provisions of this permit sEVAPORATIVE COOLERhall be VALIDATION
deemed revoked. FURNACE: FAU GRAVITY a
LICENSED CONTRACTORS DECLARATION FLOOR: 8TUi:i: m^
pct i
I hereby affirm that I am licensed'under provisions of Chapter HEATER: SUSPENDED UNIT jet` °4L1-�
9 (commencing with Section 7000) of Division 3 of the Busi- WALL v
ness and Professio I�1,u �+ i my license is in full force and Q O
effect. 11_1 �J C�V 1 cee n��¢-G (�l(; �t/(1 s i'• .<<
License Number ��'�'� Lic.Class '=j-•...
�/ AL J.�
i6tei�S r BCi �A-L.� iJJ v(t� VV 'i c
Contractors C:flpp�t•(_ Dated I Z ��� `,�' Z �� IIr •v
=tl—
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Q. I am exempt from the licensing requirements as I am a I ( $ Iv; �-7g}t3 '
.licensed architect-or a registered professional'engineer Plan check fee 25%of above. v
acting in my professional capacity (Section 7051, Bus- ` PERMIT ISSUING FEE $'
iness and Professions'Code).
Lic.or Reg.No. Date TOTAL FEE t— Z CRL7 f
132
NOME 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, Bum-
ness and Professions Code): ADDRESS
I, as owner of the property, will do the work and the
structure is not intended or offered for. sale (Section CITY TEL.NO.
7044,Business and Professions Code). OWNE
RQ — -
0 I, as owner-of the-property, am exclusively contracting A � 7_ �lC�xAb f `
with licensed contractors to construct the• project. MAIC
(Section 7044, Business and Professions Code). ADDRESS " w
- k f
CONSTRUCTION LENDING AGENCY CITY ' ,Rc�\c�G. E O. ;
I hereby affirm that there is a construction.lending agency
for the performance of the work for which this permit is CONTRACTOR
issued(Sec. 309^ C v,.•C;l. \
Lender's Name C_\ � �L�� ADDRESS } Go
Lender's Address S x)zox 6� 1 kAILLC'Yl�Y,_ CITY g T NO.
I certify that I have read this application and state that t eSTATEl �_ LIC.JIn
above information is correct.I agree to comply with all County LICENSE NO. �L4�_'1 CLASS
ordinances and State laws regulating Heating, Ventilating and
Air Conditioning, and hereby authorize representatives of this SEE REVERSE.FOR EXPLANA-TORY LANGUAGE
.County to enter upon the above-mentioned property for1 'M 10 0
inspection purp s. -
41,1 Im-
Signature of Permittee Date