HomeMy Public PortalAbout9455 DAINES DR_Mechanical__ tC+2•KE.,S'.COM�..IYSAT ION DECLARATION CEA 8 8 (2-80) Q P pUC A T�O N FOR p E R i�V li LTi
I h,-:reb.1, affirm that : nave a certificate of consent to self
insure, or,a certificate of Workers'Compensation Insurance,or HEATING-VENTILATING-AIR CONDITIONING
a certified copy thereof(Sec. 3800,Lab.C.)
Policy Novi! tC2A_8Company
Certified copy is hereby furnished, u COUNTY OF LOS ANGELES BUILDING AND.SAFETY
Certified copy is filed wi h the count•building inspection ✓
FOR APPLICANT TO FILL IN BUILDING
department�� ADDRESS
Date Applican�%.vim (PRINT OR TYPE ONLY(
, C% E LOCALITY I CL
CERTIFICATE OF EXEMPTION FRVM WORKERS' NO. TYPE OF APPLIANCE'OR,EQUIPMENT FE I'
COMPENSATION INSURANCE }- NEAREST
(This section need not be completed if the work involved ABSORPTION UNIT, BTU CROSS ST. �llv�- 0
by the permit is for one hundred dollars ($100) or less.) I� DISTRICT NO. PRocESSED CU
I certify that in the performance of the work for which this t-- AIR HANDLING UNIT,CFM
t VVV
permit is issued', I•shall not employ any person in any manner 0
so as to become subject to the Workers'Compensation Laws. . BOILER, BTU _
I COMPRESSOR, BTU ( APPROVALS DATE INsv SSIGN F_RE a
Date Applicant J
. .•. }- � ROUGH Z
NOTICE.T.O APPLICANT: If, after making this Certificate of ` VENTILATION SYSTEM' S _
Exemption, you should become subject to the Workers' FINAL _
Compensation provisions of the Labor Code, you must forth-
EVAPORATIVE COOLER :.VALIDATION
with corriply with such 'provisions' or this. permit shall be
deemed revoked. FURNACE:. FAU_— GR ITY ,
LICENSED CONTRACTORS DECLARATION I FLOOR: BTU—
I hereby affirm that I am licensed under provisions of Chapter ,U HEATER: SUSPENDED UNIT
9. (commencing with Section 7000) of Division 3 of the Busi- WALL
ness and Professions Code, and my license is in full force and
effect.
License Number Lic.Class���.VQQ
Contracio//''-84WAL-EN— Date
F1I am exempt from the licensing requirements as I.am a
licensed architect or a registered professional engineer ,flan check fee.25%.Of above.
acting in my professional.capacity (Section 7051;-Bus- PERMIT.ISSUIftIG FEE$ 4Q= '
iness and Professions Code). C7
Lic.or Reg.No. - - I/ Date_ TOTAL FEE 6019.
9 9`1.-1 A
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT'
• :. #"o oto o'o.$
I hereby affirm that I am exempt from-the,Contractor's NAME- 1,.-.5,'4';V.0 Q
License Law for the following reason (Section 7031.5, Busi-•
1 .ness and Professions Code): ADDRESS o 0 o G 1 Q Q r,
❑.1, as owner of the property, will do the work and the CITY TEL. NO.
structure is not intended or offered'for sale (Section. 0 6, ' 6;-8 8
7044, Business and Professions Code).
OWNER
I as owner of the property; am exclusively contractigg
LA
with,licensed' contractors' to construct , the protect. MAIL q4�G �p1���•
(Section 7044,.Business and Professions Code). ADDRESS •J! h� �n-
CONSTRUCTION LENDING AGENCY' CIT ( C��y TEL. NOP��-
I hereby'affirm that there is a construction l :ding agency
for the performance of the work for wh ':, this permit 15. CONTRACTOR
issued(Sec. 3097,Civ.C.). ^ n •�� ��
Lender's Name ADDRESS ��J�6+•�� 7ti.lr•j� I tJ
SL
Lender's Address } " �, !�^� TEL.NO p y e
CITY 6�VV' �IS-�12-( 1
I certify, that I have read this application and state that the' : 'STATE LIC. (�' '�
above information is correct.I agree to comply With Ar County LICENSE NO. � ' CLASS C20
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 foc
�ection purr.��s.— Q " -,. •
Signature�. Pern-: gee Date -