HomeMy Public PortalAbout9677 BLACKLEY ST_Mechanical__ WOR DECLARATION 7EA 8$,2 .80, p p b OCA Q T p O N FOR p C R�i]�ll
I hereby affirm that I have s certificate of consent to self
insuie, or a certificate of Workers'Compensation Insurance,of fr�Il��IR9�_M[ `��I�Ga7 IfJ�_G1IG� �oc��I�I��oc��
a cert;fieU copy thereof(Sec. 3800,Lab.C.)
Policy No.. Company
Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING ARID SAFETY
Certified copy is filed with the county building inspection FOR APPLICANT TOEI LL IN BUILDING
department. ADDRESS (® �/✓� q
Date Applicant (PRINT OR TYPE ONLY)
LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
COMPENSATION INSURANCE -NEAREST
(This section need not be completed if the work involved 'ABSORPTION UNIT, STu CRosS ST. - _0 Ade'^J O
by the permit is for one hundred dollars ($100) or less.) DISTRICT NO. PROCESSED By U
I certify -that in the performance of the work for which this AIR HANDLING UNIT,CFM f%
permit is issued, I shall not employ any person in any manner ✓ ° 0 Cr_
so as to become subject to the W rkers' Compensa io rl— S. BOILER, BTU F-
- — , APPROVALS DATE INSPECTOR'S SIGNATURE �
Date Applicant. COMPRESSORBTU_ _ __ ROUGH
NOTICE TO APPLICANT: If, after making this Certificate of _ '7 Z
Exemption, you should become subject to the Workers FINAL
Compensation provisions of the Labor Code,you must forth- EVAPORATIVE COOLER
with comply with such provisions or this permit shall be VALIDATION.
deemed revoked.
LICENSED CONTRACTORS DECLARATION FURNACE: FAU_ �VITY O
FLOOR: BTU ` O°
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. ��� ��� �� / !`
% �/ �! O
License Number Lic.Class
Contractor Date
ElI am exempt from the licensing requirements as I am a e
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 EEE $ �
Lic.or Reg.No. Date TOTAL EEE �0
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from- the Contractor's NAME �/111 —��r�-_Z1 29 1 53,9 A
License Law for the following reason (Section 7031.5, Busi- �'��
ness and Professions Code): ADDRESS /(/ /L/ 9 �yp// `1( //�� #.o o 0 0 o 8
I, as owner of the property, will do the work and the 2,o;b 2,700
structure is not intended�or offered for sale (Section CITY rL,� C�— TEL.NO. f .
�C/ r '' 2 7 0 0,=
7044, Business and Professions Code). �- ro.o to
aI as owner of the property, am exclusive) contractingOWNER /� ,
with licensed contractors yto construct the project MAIL ��'�/���//��
(Section 7044, Business and Professions Code). ADDRESS
CONSTRUCTION LENDING AGENCY CI7 �! EL. NO.
I hereby affirm that there is a construction lending agency /
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
Count' 1 enter upon the above- ntioned property for
�„sp .aio
Scure
ign of Permittee `-/�`L/ Date