HomeMy Public PortalAbout9115 DUFFY ST_Mechanical__ WORKERS'COMPENSATION DECLARATION 76A364C APPLICATION
p1p p y p� C 1p PERMIT
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1 hereby affirm that I hive u' ceriificate of consent to self CE-818 (2-80) , P9 r r L IC A 1 I O 1 tl r O R r E R M IT
insure, or a certificate of Workers' Compensation Insurance.or HEATING-VENTILATING-AIR CONDITIONING
a certified copy thereof(Sec. 3800, Lab.C.)
Policy rti Company COUNTY OF LOS ANGELES �' e
' BUILDING AND SAFETY
Certified copy is hereby furnished.
Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN BUILDING C
department. ADDRESS
Date Applicant (PRINT OR TYPE ONLY) /
LOCALITY - /y,
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE /{'�IIIC ']
COMPENSATION INSURANCE - NEAREST
(This section need not be completed If the WOlk iOVO1Ved ABSORPTION UNIT, BTUCROSS ST. 0-
by the -permit is for one hundred dollars ($100) or less.) DISTRICT NO. PROCESSEC ,y U
1 certify that in the performance of the work for which this AIR HANDLING UNIT,CFM t. O // 0
permit is issued. 1 shall not employ any person in any manner �.J Q O
so as to become subject to the Workers' Compensation Laws. BOILER, BTU
APPROVALS DATE INSPECTOR'SSIGNATUflE U
Date Applicant ! COMPRESSOR, BTU ROUGHd
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM [n
Exemption, you should become subject to the Workers' FINAL r Q'( Z
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATIOPV
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU_�RAVITV_
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.
License Number Lia Class
Contractor Date
1 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 $ ,fid
Lic.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 the work and the TEL. NO.
structure is not intended or offered for sale (Section CITY
7044, Business and Professions Code). -6,2 5 Q 0 A
❑ OWNER �2 r �_.l.c_r�'J•9' . . .,. .
I, as owner of the property, em exclusively contracting d-1 with licensed ctintractors to construct the project MAIL ADDRESS
5�{ /
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(Section 7044, Business and Professions Code). _
CONSTRUCTION LENDING AGENGy CITY ,moi /Te�NO.��S3
_ �.
I hereby affirm that there is a consrruction lending age cy - e e e 3 g 5 Ojo
for the performance.of the work for which this permit is CONTRACTOR
issued (Sec. 3097,Civ.C.). - - )• 1 V-82
Lender's Name ADDRESS
Lender's Address CITY U TEL. NO: '
1 certify that I have read this application and state that the
STAT
E (/ LIC.
above information is correct.1 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
CuPm> Denter ihtiovdm�tTe�property for
V�gnature f Permittee Date -