HomeMy Public PortalAbout9575 BLACKLEY ST_Mechanical__ 76A364C
WORKERS'COMPENSATION DECLARATION CE -818 (2-80) 6�=%P 1(— L 0C d=al T�ON FOR P E R WT
I hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers'Compensation Insurance,or HEATING-VENT ILATING-Al
ffd CONDITIONINGa certified copy thereof(Sec. 3800,Lab.C.)
ECertified copy is hereby furnished.
Policy Company COUNTY OF LOS ANGELtS -
' A BUILDING ARID SAFETY
El Certified copy is filed with the county building inspection
department. FOR APPLICANT TO FILL IN• ' BUILDING
Date Applicant (PRINT OR TYPE ONLY) AODRESSrl�'2�
LOCALITY /
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE /s_ `I Y
COMPENSATION INSURANCE NEAREST }
(This section need not be completed if the work involved ABSORPTION UNIT, BTU CROSS ST. ���° l ' aO
by the permit is for one hundred dollars ($100) or less.) DISTRICT NO. - PFIOCESSE00<1U
I certify that in the performance of the work for which thisAIR HANDLING UNIT,CFM /T�
permit is issued, I shall not employ any person in any manner
if/�' , cc
so as to become subject to the Workers"Compensation Laws. BOILER, BTU
Date / / - �� APPROVALS DATE INSPECTOR'S SIG E d
����Applicant COMPRESSOR, BTU ROUGH N
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers' _
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION
with comply with such provisions or. this permit,shall be
deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOnR: BTU
I hereby affirm that I am licensed under provisions of Chapter HEATER: SUSPENDE UNIT
9 (commencing with Section 7000) of Division 3 of the Busi- - WALL ��'f� 00 Jt�
ness and Professions Code, and my license is in,full force and
effect. C 3 1
5`���
License Number^� Lic.Class
ContractorA%4—.. /xe I - •
I am exempt from the lice Ing requirements as I am a
licensed architect or a registered professional engineer Plan check fee 25%of above.
acting in my professional*capacity (Section 7051, Bus- '
iness and Professions Code). PERMIT ISSUING FEE$ �
Lic.or Reg.No. Date TOTAL FEE
HOME OWNER-BUILDER DECLARATION PLAN CHECK.APPLICANT '
I hereby 'affirm that I am exempt from-the Contractor's NAME� y—`G�
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): ADDRESS/ -7
I, as owner of the property, will do the work and the C,6G` ���
CITY TEL. NO.T,66— D
structure- is not intended or offered foi sale (Section �2'0 9;3 A
7044; Business and Professions Code). �
OWNER ,
I, as owner of the property, am exclusively contracting'! �4 q '# oolo:'o
, 41
-with licensed contractors to construct the project MAIL f /► J
(Section 7044, Business and Professions Code). ADDRESS TI S /.� �Xr G 2!-:- 217, 0 0
CONSTRUCTION LENDING AGENCY CIT'. 'C r TEL.NOX IF jo 0 0
r y 2'7,00r2
I hereby affirm that there is a-construction lending agency. /
for the performance of the work for which this .permit is CONTRACTJR��� 4 ,�/�'� 9, _$0
issued (Sec. 3097,Civ.C.).
Lender's Name ADDRESS /6 /1 � •Se
� R
Lender's Address CITY �� ' TEL. NO.(t 6G'
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 N0.3/.Sod T 0 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
inspection purposes.
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Signature of ermittee Date