HomeMy Public PortalAbout10561 DANBURY ST_Mechanical__ KERS'C'ONIPENSATION DECLARATION 76A364C APPLICATION
1�f� py- p� FOR
PERMIT
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ffirm that I have a certificate of consent to self CE-818 (2-80) /"iIf— IrLICA 1 'ON 1�" OR IrERM8certificate nt Workers'Compensation Insurance,or HEATING-VENTILATING-AIR CONDITIONING
opy theopf(See. 3800.Lab.C.)
Z(Q'ompan>—iNed copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
ed copy is fled with the county building inspection BUILDINGFOR APPLICANT TO FILL IN / �'• (� a ADDRESSOStOI G. DAaBU
—="z-Applicam— - - (PRINT OR TYPE ONLY)
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' `
COMPENSATION INSURANCE NEAREST }
CROSS ST. L M Lam_ d
(This section need not he completed if the work involved ABSORPTION UNIT, BTU O
by the permit is for one hundred dollars ($100) or less.) DISTRICT NO. / PROCESSED By L)
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM R [ f/ O
permit is issued. I shall not employ any person in any manner '/ n a
so as to become subject to the Workers' Compensation Laws. I 801 LE R, BTU S4Q0,1.GbO
APPROVALS DATE INSPECTOR'a SIGNATURE W
Date APplaant COMPRESSOR, BTU �'
0.
ROUGH U)
NOTICE TO APPLR ANI : 11, after making this Certificate of VENTILATION SYSTEMZ
Exemption, you zhnuld become subject to the Workers' FINAL �a'Y+Z )C•.a-r�JJ. —
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION V
with comply with such provisions or this permit shall be
deemed revoked- FURNACE: FAU_ GRAVITY
LICFNSFD CONTRACTORS DECLARATION - FLOOR: BTU
I herehy 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 Pr+fessinns Code, and my license is in full force and
effect. ��..r
License Number��Sav r„�_ Lic.Classl�1 / �q�7 _
Contractole,M__1@00LJS_ Date
I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer Plan Check fee 25%of above.
actin_e in my professional capacity (Section 7051, Bus- — -
iness and Professions Code), PERMIT ISSUING FEE $
Lie.or Reg.No. Date. TOTAL FEES
HOME OWNER-BUILDER DECLARATION PLAN CHECK pAPPLICANT p
1 hereby affirm that 1 am exempt from the Contractor's NAME FU PO LSINC.
License Law for the following reason (Section 7031.5. Busi- D� r
NAS DR1VE
Dass and Professions Cod.): ADDRESS SAN GABRIEL 514 '
1, as owner of the property; will do the work and the - - .�c s ., r ;23,6116A
structure is not intended or offered for sale (Section CITY TEL. NO. 2S 2-2,& .
70444 Business and Professions Code). G— #Io tare o Is 8
❑ OWNER —Ptr`A Pet_. �.J�I N��
1, as owner of the property, am exclusively contracting o`o 3 3.5 0
with licensed contractors to construct the project MAIL 1,, .z -f
lo
7044, Business and Professions Code). ADDRESS IOS(o t C—. !7 btJr
CONSTRUCTION LENDING AGENCY CITYT��V.Ap TL.NO. qQ1 ,
�_C1_
E
35
I hereby affirm that there i' a construction lending agency CONTRACTOR 0L6�82
tvor
for the performance of the k For which this permit is
issued (Sec. 3097,Civ.C.). C-AtIf O RKA-PID
Lender's Name f ADDRESS
U V �r INC.,
N�� 6B06USf-LAS-T"A�R1VE
Lender 's Atldress
CITY SAN GABRIEL, CALIrI5hhI '_9.1Z7A
I certify that I have read this application and state that the STATE �C( 5 I O n LIC.
above information is correct.I agree to comply with all County LICENSE NO. VV 1 _!/ CLASS J
ordinances and State laws regulating Heating, Ventilating and
Air ' �nditipning,and her :, authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
Cot , y to enter u- t t4 : above-mentioned property for
htq aeon purposes �/'���
-ago, 'are of Permittee _ Date