HomeMy Public PortalAbout9160 EMPEROR AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION CEA 8 A P P018 (2-80) IL,,UC A T�O �l FOR PER 9�%U T
I hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers'Compensation Insurance,or 6�IE�aYIYl1Cx.l1fERlTILI�+YIWCs-i�ICa COW®IY IONI�Cv
d certified copy thereof(See 3900,Lab C)
Policy No Company
Certified copy is hereby furnished COUNTY OF,LOS ANGELES BUILQING AND SAFETY
-
_ e ,
Certified copy is filed with the county building inspection -
department FOR APPLICANT TO'FI LL IN /BUILDING +rpt-
1(] _ �i.i�/CV-6 IR
Date Applicant (PRINT OR TYPE ONLY) ADDRESS
_ LOCALITY Te e 't'
CERTIFICATE OF EXEMPTION FROM WORKERS' c NO TYPE OF APPLIANCE OR EQUIPMENT FEE I/I�1_r 1.�A�
COMPENSATION INSURANCE w - — NEAREST
(This section need not be completed if the Work involved ABSORPTION UNIT, BTU CROSS ST D a'< ,�� �ti, O
by the permit 1S for one hundred dollars ($100) or less) DISTRICT NO ) PRoc �� ,e U
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM tr
permit is issued, I shall not employ any person m any manner (�
so as to become subject to the Workers' Compensation Laws BOILER, BTU
APPROVALS DAT INSPECTOR s SIG �URE " fJ
Date' Applicant �G�
COMPRESSOR,BTU 4 v�VV w
ROUGH d
NOTICE TO APPLICANT If, after making this Certificate of N
Exemption, VENTILATION SYSTEM FINAL — z
p you should become subject to the Workers'
Compensation provisions-of the Labor Code, you must forth-
with comply with,such provisions or this permit shall bera
EVAPORATIVE COOLER VALIDATION
deemed revoked FURNACE FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU_I(S�orJ
I hereby affirm that I am licensed under provisions of Chapter HEATER SUSPENDED UNIT
9 (commencing with Section 7000)of Division-3 of the Bust- WALL '
ness and Professions Code, and my license is in full force and
effect _
License Number Lie Class
Contractor Date
j `
ElI am exempt from the hLensing requirements'as I am a
licensed architect or a registered professional engineer Plan check fee 25%of above I „
acting in my professional capacity (Section 7051, Bus-"
iness and Professions Code) PERMIT ISSUING FEE $
Lie 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 aw for the following reason (Section 7031 5, Busi-
Hess .nd Professions Code) ADDRESS
r ,�J 'A�el�vl
I, as owner of the property, will do the work and the CITY TEL NO
structure is not intended or offered for sale (Section _0-,&t/lkurr_B_V+-,
7044,Business and Professions Code)O p OWNER, JLaVK`Li _ �i� b1,.7 A
I, as owner of the property, am exclusively contracting
withlicensed contractors to construct the project MAIL # o'Ioio 0 0 8`
(Section 7044, Business and Professions Code) ADDRESS
CONSTRUCTION LENDING AGENCY CITY TEL NO 2 -[o 417,0 O
I hereby affirm that there is a construction lending agency _ _ }
for the performance of the work for which this permit is CONTRACTOR ;°i°to 417;Q'0 5
issued(Sec 3097,Civ C)
Lender's Name ADDRESS _` �%% 1 0 2 0,-81,1
Lender's Address CITY .TEL _
I certify that I have read this application and state,that the STATE LIC
above information is correct I agree to comply with all County I LICENSE NO CLASS, _
ordinances and State laws regulating Heating, Ventilating and
Air Conditioning, and hereby authorize representatives of this SEE REVERSE rOR EXPLANATORY LANGUAGE
County to enter upon the above-mentioned property for
uisp n n �urpos
Signature of Permitt a i!40 .. -_ _ _ __ _ ___ _ "� �« • _ _ _.... _ ._ _ _