HomeMy Public PortalAbout5324 FRATUS DR_Mechanical__ WRKEthat J'have cerci DECLARATION APPLICATION FOR PERMIT
by affirm that J have a certificate�nsat
f
/insdhe, or o certifTate of Workers',Compe , 76A364c HEATING - VENTILATING - AIR CONDITIONING
or a certrfied copy thereof(Sec 3800, Lab
CE-818(REV 10/81)
r PolicyNo-Company
Certified copy Is hereb rr sled COUNTY OVLOS ANGELES BUILDING AND SAFETY
❑ Certified copy I ed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING
tion depart nt ADDRESS 5 lCra�t�5
(PRINT OR TYPE ONLY)
Date Applicant LOCALITY
.NO TYPE OF APPLIANCE OR EQUIPMENT FEE I�
CERTIFICATE OF EXEMPTION FROM WORKERSNEAREST n.
COMPENSATION INSURANCE CROSS ST nil
NO PROCESSED BY '
(This section need not be completed if the work involved by ABSORPTION UNIT BTU DISTRICT
the permit is for one hundred dollars ($100)or less )
AIR HANDLING UNIT CFM
I certify that in the performance of the work for which this
permit Is Issued, I shall not employ any person in any manner BOILER, BTU
so as to become subject to the Workers'Compensation Laws - APPROVALS DATEINSPE OR S SIGNATURE
Mn o COMPRESSOR, BTU (J 000 ROUGH
Date g Applicant
NOTICE TO APPLICANT If, after making this Certificate of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER I VALIDATION
with comply, with such provisions or this permit shall be
deemed revoked FURNACE FAU GR VITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU v
j hereby affirm that I am licensed under provisions of Chapter 9 HEATER, SUSPENDED UNIT
(commencing with Section+7000) of Division 3 of the Business WALL a
and Professions Code,and my license is in full forceej effect
/ / !i
License Number 7d9ab Llc Class O O
//,,b
Contract❑ E'j Date 2.2 e5Z8 7 _ 0
❑ I am exempt under Sec UA
Plan check fee H
B &P C for this reason �
Date PERMIT ISSUING FEE $ S �7 8 G 4 A
TOTAL FEE
" Signature # o'? e e o
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from The Con tar's License ' ' e [� a Q
Law for the following reason (Section 7 5, Business and NAME
Professions Code) • •�e 4 a 0 0 X0
❑ I, as owner of the pro or m employees with ADDRESS ,
wages as Their sole co pen�ation,will do he work and CITY' TEL NO 9, $ 8 7
the structure is no ntended or offered for sale(Section
7044, BUS
nd Professions Code) `
❑ OWNER
I, as ow r of the property, am exclusively contracting kA
with censed contractors to construct the project (Sec- MAIL �•/
tion 7044, Business and Professions Code) ADDRESS �Q�p (,�J L IVp�s
CONSTRUCTION LENDING AGENCY -CITY TEL NO�9 6 6
I hereby affirm that there Is a construction lending agency for t'"t �� 33-C
the performance of the work for which this permit is Issued CONTRACTOR I '/
(Sec 3097, Civ C ) C Q HSG. t N -4-Af R
ADDRESS qD 2- S. V i A)e -
`Lender's Name '
CITY ` TEL NO 7 t _G 3L/
Lender's Address - � 6 ,
STATE LIC
I certify that I have read this application and state that the LICENSE NO60pZa�j CLASS
above information Is correct I agree to comply with all County ,
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter
upon the above-mentioned property for Inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date