HomeMy Public PortalAbout5125 FRATUS DR_Mechanical__ W(-,RKi:RS'CON4PENSATiON DECLARATION 76A364C
hereby affirm that I have a certificate of consent to self CE-818 (2 80) Q p p(���Q`� Oo ®G�3 p C ( 0`l�
insure, or a certificate of Workers'Compensation Insurance,or HEATING-VENTILATING-AIR CONDITIONING
a certified copy thereof((Seee3800, Lab C
Policy N 7 r !c npa6p �' COUNTY OF LOS ANGELES BUILDING ARID SAFETY
Certified copy is hereby furnished
Certified copy is filed with the county building inspection BUILDING
J rlen�•tment � /,�,� i FOR APPLICANT TO FILL INBUILDING
S I`kfl'i�/,(' �fL
Date_6—?i.r Applicant !� �"�'� (PRINT OR TYPE ONLY)
LOCALITY 7 e* 6� �(
CERTIFICATE OF EXEMPTION FROM WORKERS' NO TYPE OF APPLIANCE OR EQUIPMENT FEE
COMPENSATION INSURANCE NEAREST }
(Thus section need not be completed if the work Involved ABSORPTION UNIT, BTU CROSS ST a0
by the permit is for one hundred dollars ($100) or less) DISTRICT NO PROCESSED BY U
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM d (�' er
permit is issued, I shall not employ any person in any manner AO s', d O
so as to become subject to the Workers' Compensation Laws BOILER, BTU— �i� 0
APPROVALS DATE INSPECTOR S SIGNATURE W
Date Applicant COMPRESSOR,BTU ROUGH iL
NOTICE TO APPLICANT If, after making this Certificate of VENTILATION SYSTEM —,04Z
Exemption, you should become Si_bject to the Workers' FINAL —
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
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 qq _
License Number `j �� Lic Class '7
i
ContractoJk�?�&/1l Date 7
El1 am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer Plan check fee 25%of above
acting to my professional capacity (Section 7051, Bus-
iness and Professions Code) PERMIT ISSUING FEE $
Lic or Reg No Date TOTAL FEE >O
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from-the Contractor's NAME BW 0 4 7 A
License Law for the following reason (Section 7031 5, -Busi-
ness and Professions Coda) ADDRESSI
1, as owner of the property, will do the work and the # 0,� � 8
structure is not intended or offered for sale (Section CITY TEL NO 2 -',,- 3 3,'5 0
7044, Business and Professions Code) �y ;
aOWNERC1!V.
i, as owner of the property, am exclusively contracting - �a'�to 33505
with licensed contractors to construct the project MAIL _
(Section 7044 Business and Professions Code) ADDRESS Q U 9-82
CONSTRUCTION LENDING AGENCY CITY TEL NO
I hereby affirm that there is a construction lending agency f�
for the performance of CONTRACTOR the work for which this permit is
issuedSec 3097,Civ C) d� � (' )J,��d�7'
Lender's Name ADDRESS J V -
Lender's Address CITY 0�lf flyza TEL NO7f--?J j0 3
I certify that I have read this application and state that the STATEU 3 LIC C —
above information is correct I 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
County to enter upon the above-mentioned property for
uispNct�pose��r�
Signature of Permittge Date