HomeMy Public PortalAbout4870 FRATUS DR_Mechanical__ WORKERS'COM.ENSA MON DECLARATION CEA 8 8 (2-80) I P P UC A T B®N FOR If- E R WT
I hereby affirm'chat I have a certificate of consent to self
insure, or a certificate of Workers'Compensation Insurance,or HEATING-VENTILATING-AIR CONDITIONING
a certified copy thereof(Sec 3800,Lab C)
Policy No Company
El Certified copy is hereby furnished COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN BUILDING
department ADDRESS 20
Date Applicant (PRINT OR TYPE ONLY)
CERTIFICATE OF EXEMPTION FROM WORKERS'
NO TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITYT(���G� G1 l j
COMPENSATION INSURANCE NEAREST CROSS ST 6Q/o .14,0 }
(This section need not be completed if the work involved ABSORPTION UNIT, BTU a
by the peririit is for one hundred dollars ($100) or less) v DISTRICT NO PRO 6Y O
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM !
permit is issued, I shall not employ any person in any manner tr
so as to become subject to the Workers' Compensation Laws BOILER, BTU
APPROVALS DATE INSPECTOR S SIG RE U
Date Apphi Ant COMPRESSOR,BTU ROUGH d
NOTICE TO APPLICANT If, after making this Certificate of VENTILATION SYSTEM FINAL Z
Exemption, you should become subject to the Workers' _
Compensation provisions of the Labor Code you must forth- EVAPORATIVE COOLER ' VALIDATION
with comply with such provisions or this permit shall be
deemed revoked FURNACE - FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter HEATER SUSPENDED / UNIT
9 (commencing with Section 7000) of Division 3 of the Bus[- If WALL
ness and Professions Code, and my license is in full force and
effect
License Number Lic Class
Contractor Date
0 1 am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer Plan check fee 25%of above
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code) PERMIT ISSUING FEE$
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, Bust-
nes,and Professions Code) ADDRESS
I, as owner of the property, will do the work and the CITY TEL NO
structure is not intended or offered for sale (Section
7044, Business and Professions Code) n S
❑ OWNER /'r C�
I, as owner of the property, am exclusively contracting 2 1 '7 2,3 A
with licensed contractors to construct the project MAIL �/G�O
(Section 7044, Business and Professions Code)- ADDRESS /f U ���'�T Y�
#'o 01 0 4 1
CONSTRUCTION LENDING AGENCY CITYt7lPC�i' / -TEL 1\10.26'!; .j J
I hereby affirm that there is a construction lending agency 2',0 o 217 0 0
for the performance of the work for which this permit is CONTRACTOR e�
issued (Sec 3097,Civ C) w� o o o 2 7.0 0 5
Lender's Name ADDRESS
Lender's Address CITY . -TEL NO 0 1 4%-810
1 certify that I have read this application and state that the STATE LIC
above information is correct I agree to comply with all County LICENSE NO CLASS
ordinances and State laws regulating Heating, Ventilating and
Air Condition,i � d hereby author - representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
County t [er pon t' abo a entioned property for
uispeurpo,
C .�
ignature of Per mir'.e Date