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Home My Public Portal About9081 EMPEROR AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION CEA 8618 C(2-80) Q p p ��Q� O I� (BOO G C 0 I hereby affirm that I have a' certificate of consent to self insure, or a certificate o4 Workers'Co nsation Insuranc-,or brQ�I��•d��I�I�ca��c�c -QIc� ©��I�IOI��c�c� a�r,rVf�i thereof(Sec. 3800,L.f. ,.� (licy No.' -- a✓®a�l�Tv OF LOS e�NGEI_ � VDI ®IiMG AND SAFETY Vue tified copy is hereby urnished. � ytified copy is filed with the county building inspection department. FOR APPLICANT TO FILL IN BUILDING ADDRESS Q Date Applicant (PRINT OR TYPE ONLY) CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITL/ COMPENSATION INSURANCE NEAREST (This section need not be completed if the work involved ABSORPTION UNIT, STU� CROSS ST. O by the permit is for one hundred dollars (5100) or less.) % DISTRICT NO. JPtR1'^FS�_J BY U 1 certify that in the performance of the work for which this AIR HANDLING UNIT,CFM 1 permit is issued, I shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws. I BOILER, BTU 1— APPROVALS DATE INSPECTOR'S SIGNATURE V W Date Applicant COMPRESSOR,BTU ROUGH fa NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEMFINAL ►�` Z Exemption, you should become subject to the Workers' r � Compensation provisions of the Labor Code, you must forth- with comply with such provisions or this permit shall be EVAPORATIVE COOLER � � VALIDATION deemed revoked. FURNACE: FAU GRAVITY 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 Lic.Class Contractor Date I am exempt from the licensing requirements as ( 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). PERM27 ISSUING PEE � Lic.or Reg.No. Date TOTAL FEE ®� 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 El I, as owner of the property, will do the work and the TEL. NO. structure is not intended or offered for sale (Section CITY ` 0 8 9 1 A 7044, Business and Professions Code). D � r � # I, as owner of the property, am exclusively contracting OWNER o'.o,o o 6 8 with licensed contractors to construct the project MAIL (Section 7044, Business and Professions Code). ADDRESS 2 °I° 1 3 0 0 CONSTRUCTION LENDING AGENCY CITY TEL.NO. 0.0 0 1 3,0 0 v I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is CONTRACTOR / . �� 0 8 2 5—8-1 issued(Sec. 3097,Civ.C.). — r Lender's Name ADDRESS40 Lender's Address CITY 'may TEL.NO. C7 i1Clkj I certify that I have read this application and state that the STATE �f�` LIC• above information is correct.I agree to comply with all County LICENSE NO. W'0� 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 up n the above-mentioned property for inspe ion purp es. Signature of fermi a 6ate