HomeMy Public PortalAbout9939 BROADWAY_Mechanical__ WORKERS'COMPENSATION DECLARATION 76A364C
1 5ereby aGirm that I have a certificate of consent to self CE -818 (2-80) APPLICATION FOR P E R M.IT
insure, or a certificate of Workers'Compensation Insurance,or HEATING-VENTILATING-AIR CONDITIONING
a certiil;-A cony thereof(Sec 3800.Lab. C.) '
Policy NF Oct 3 7 npanY�4tt- _F-4- i-q. ,
❑ Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
S�AFFETY�P�.�/
Lk Certified copy is filed with the county building inspection BUILDING r/ G,iYCGF� U /
department -t/,tt ^ ^ FOR APPLICANT TO FILL IN ADDRESS "( 7 l
Date�.=—o.�Applicant_L/l__��_''!W L(..� (PRINT OR TYPE ONLY)
CERTIPICATE OF EXEMPTION FROM WORKERS'
NO, TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY
COMPENSATION INSURANCE NEAREST
(This Section need not be completed if the work involved ABSORPTION UNIT,BTU CROSS ST. d
by the permit is for one hundred dollars ($100) or less.) o15TRicT Na. PRocEssEo eY O
I certify that in the performance of the work for which this. AIR HANDLING UNIT,CFM
permit is issued, I shall not employ any person in any manner cc
so as to become subject to the Workers' Compensation Laws. BOILER, BTU _ O
APPROVALS DATE INSP CTORS GNATURE U
-Date _ Applicant C,. COMPRESSOR,BTU Q�� U S
ROUGH
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL r �" Z
Exemption, you should become subject to the Workers' _
Compensation provisions of the Labor Code, you must forth EVAPORATIVE COOLER VALIDAI ION
with. comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU— -RA tITY_ 1
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. //'p /�
Li�censesNN�uym�ber_7 /-1,0,_K6LiC..Class o. a .�2 2 2'2 A _
Cr;.itractc_ �C'� yate L �y # 8
❑ I am exempt from the licensing requirements as I am a �, 2 Q 5 0
,licensed architect or a registered professional engineer Plan cheek fee 25%Of above.
acting,in my professional capacity (Section 7051, Bus-
iness and Professions Code). PERMIT ISSUING FEES (6 SU • ! 20505
Lie.or Reg.No. Date TOTAL FEE o 6 O7 7 8 5
HOME 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, Busi-
ness and Professions Code): ADDRESS
❑ 1, 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). 7� t
❑ OWNER
I, as owner of the property, am exclusively contracting ��CS( f ✓1/rl '✓�t�G�'�i
with licensed cusinestprs to construct the project MAIL
(Section 7044,.Business and Professions Code), ADDRESS
CONSTRUCTION LENDING AGENCY CIT1_ . C TEL. NO&9 q7S�j
I hereby affirm that there is a construction lending agency �I—! /
for the performance of the work for which this permit is CONTRACTO F. At C_ � Y�
issued (Sec.3097,Civ.C.). L
Lender's Name ADDRESS S�.`l✓- "t per
Lender's Address 'CIT.- �„ o y ``q''`}'-y TEL.'NO.
I certify that 1 have read thisapplicationand state that the STATE ` d+^�-/y--r If'�y ` LIC.
above information is corrdtt. !agree to comply with all County LICENSE N.O. 2 ! �!O k 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 _ / --�
SignnlSre of Permittee Dale