HomeMy Public PortalAbout9168 FORTSON DR_Mechanical__ WORKERS'COMPENSATION DECLARATION CEA 818 (2-80) APPLICATION FOR P E R UVU T
I hereby affirm that I have a certificate of consent to self
insure, ,certificate of Workers'Compensation Insurance,or FIIEATING-VENT ILATING-AIRd CONDITIONING
a'ceriifi_ed c� .�. ,f(S`T8—r.. jr.C.)
Policy WW. `o Compan�y COUNTY OF LOS ANGELES BUI LDI�ARID SAFETY
Certified copy is hereby furnished.
Certified copy is filed with the county building inspection BUILDING (�
..t. / ,Qn/ FOI; APPLICANT TO FILL IN �j
Date
t. ADDRESS
Applicant.__ _ _ __ _/ !�T� (PRINT OR TYPE ONLY) ADDRESS _ �L ��
LOCALITY G
CERTIFICPTE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
JOMPENSATION INSURANCE NEAREST
(This section need not be completed if the work involved' ABSORPTION UNIT, BTU CROSS ST: a
by the permit is for one hundred dollars ($100) or.less.) DISTRICT NO. PROCESSED .0
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM 0
O
permit is issued, I shall not employ,any person in any manner
so as to become subject to the Workers'Compensation Laws. BOILER, BTU
• APPROVALS DATE INSPECTOR'S SIGNATURE V
Date ROUGH
Applicant- COMPRESSOR, BTU f 2 d
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM to
Exemption, you should become subject to the' Workers' FINAL Z
Compensation provisions of the Labor Code, you must forth- EVAPORATIVECOOLER VALIDATIO
with comply with such provisions or this permit shall be
deemed revoked.
FURNACE. FAU GRAVITY—
LICENSED
RAVITY LICENSED CONTRACTORS DECLARATION FLOOR: BTU
I hereby affirm that I am licensed under provisions of Chapter HEATER: SUSPENDED UNIT
9 (commencing with Section 7000) of Division 3 of the Busi- WALL
ness and`Professions Code, and my license is in-full force and
effect. 0Z
License Number Lic.Cla$s
Contractor Date.—
ElI 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 $
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
OI, as owner of the property, will do'the work and the
structure is not intended or offered for sale (Section CITY TEL. NO.
7044,-Business and Professions Code).
r7_1
OWNER
I,as owner of the property, am exclusively contracting
with -licensed contractors to construct, the project MAIL
(Section 7044, Business and Professions Code). ADDRESS 141:51, 2 2 4 A
CONSTIIUCTION LENDING AGENCY CITY T�, TEL.t 8 41��•
I hereby affirm that there is a construction lending agency o a'o - 4 1
for the performance of the work for which this permit is CONTRACTOR
issued (Sec. 3097,Civ.C.). —— —— 2 n o 2 7, Q
Lender's Name ADDRESS^� /�
Lender's Address CITY TEL.,N
I certify that I have read this application and state that the STATE .�� /� LIC. /^ p1 o9,2'5—•8 0
above information is correct.I agree to comply with all County LICENSE NO. X1(7 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 -upon the above-mentioned property for
msnPn p• rises
Aignaeture ur Permitt
eee Dat /