HomeMy Public PortalAbout9647 BROADWAY_Mechanical__ If ' 76A364C WORKERS'COMPENSATIONDECLARATION CE -818 (2-80) APPLICATION
P r L--IC- .AyI. pFR PERMIT
I hereby affirm that I have a certificate of gonsent to self
insure,or a certificate of Workers'Compensation Insurance,or �rHEATING-V ENTILATIPIG-AIR CONDITIONING
a certified copy thereof(Sec.3800,Lab.C.)
Policy No. Company '
F-1 Certified copy is hereby furnished• p _- COUNTY OF LOS ANGELES BUILDING AND SAFETY -
0--clrtified copy is filed with ti,_ county t wilding inspection -
////���� n�/I FOR APPLICANT TO FILL IN BUILDING Q/ �(
delIpartm nAt. �� /V n L ADDRESS 9&47
Date—'I_�G��i Applicant_ r- /VVVVr�j+,...A. �(j,� � � (PRINT OR TYPE ONLY). _ `
u NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY I
CERTIFICATE E EXEMPTION FROM WORKERS' - -COMPENSATION INSURANCE NEAREST gr ' ' �
(This section need not be completed if the work. involved ABSORPTION UNIT;BTU - WW'D
CROSS ST. • ' �c r17` LIl O
y the permit is for one hundred dollars ($I00) or less.) DISTRICT NO. P60CESSEGay t)
(!his
that in the performance of the work for which this Al R ANDLING UNIT,CFM .. ,�.
permit is issued, I shall not employ any person in any manner iJ v - O
so as to become subject to the Workers' Compensation Laws. BOILER, BTU.
,/tI �j �// APPROVAS 'DATE ' 'INSPECTORS SIGNATURE W
Date _6/r I_ Applicant_rLy,lcl_._/_T_C16�J2.a3/ COMPRESSOR,BTU ROUGH / y --C/ tap
C/ �l_U
NOTICE TO APPLICANT: If, after making this ertificate of VENTILATION SYSTEM FINAL - Z
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
VALIDATION-
deemed revoked. FURNACE: - FAU— GRAVITY—
LICENSEDCONTRACTORSDECLARATION FLOOR: BTU O
1 hereby affirm that I am licensed under provisions of Chapter HEATER; ENDED UNIT
9 (commencing with Section 7000) of Division 3 of the Busi- WALL .��Ce.?Cj
ness and Professions Code. and my license is in full force and 0!� /3
effect. ( fd
License Number-13yb22._ Lic.Class-6-.
❑ 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-
iness and Professions Code). PERMIT ISSUING FEE $ -7
Lie.or Reg.No. Date TOTAL FEE
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT'
1 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
❑ 1, as owner of the property, will do thework and the - TY TEL NO.
structure is not intended or offered for sale (Section CII z 3'6 2 7 A
7044, Business and Professions Code).
❑ OWNER 1 I14 # e,o o [(
1, as owner of the property, am exclusively contracting r_ �/yl
with licensed contractors to construct the project MAIL ,' 2,e.e .7,00
,(Section 7044, Business and Professions Code). ADDRESS �ory� l]jzCA
,(y�/�, .
CONSTRUCTION LENDING AGENCY CITY 1 �' TEL.NOZ� $1(4 e s o 7 O Q v
I hereby affirm that there is a construction lending agencyC
for the performance of the work for which this permit is CONTRACTOR Q 6_$ 1issued (Sec. 3097.Civ.C t �n -I--N'-Z.\_f,Z— t.�N$:Ti ,
Lender's Name �—' ADDRESS 2
Lender's Address 3 S
CITY
L. NO B i
I certify that I have read this application and state that the STATE
AII/II�L -TELIC
above•information is correct.I agree to comply with all County LICENSE NO. I �tb Z--ZCLASS
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�,pection part rSes.
Signature of Permit a Da•.