HomeMy Public PortalAbout10679 FREER ST_Mechanical__ WORKERS'COMPENSATION DECLARATION 7 EA A3
8�(�_Bo,_ q p•p UC Q T p O N FOR p E RWT
I hereby affirm that I have •a' certificate of c:;lsea. t 'Self - -
insure, or a certifical,;of WorlZers'Compensation Insurance,or I HEATING-VENTILATING-AIR CONDITIONING
a certified copy thereof(Sec. 3800,Lab.C.)
Policy No. Company
Certified copy is hereby furnished. - COUNTY OF LOS ANGELES . BUILDING ARID SAFETY
Certified copy is filed with the county building*inspection BUILDING
department. FOR APPLICANT TO FILL'IN ADDRESS��G�� � _�
Date Applicant (PRINT OR TYPE ONLY)
LOCALITY _
CERTIFICATE OF EXEMPTION FROM WORKERS' NO.' TYPE OF APPLIANCE OR EQUIPMENT FEE
COMPENSATION INSURANCE NEAREST ./}-��/ }
(This 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 (�
IR HANDLING UNIT,CFM
I certify that id the performance of the work for which this A � � � _ cc
permit'is issued, I shall not employ any person in any manner - -LC�O�= 0
so as Lo become subject to the Workers'Compensation Laws.. BOILER, BTU —�
APPROVALS DATE INSPECTOR'S U
W
Date Applicant COMPRESSOR,BTU ROUGH- / �"� CL
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL j"�� /(G 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: FAURAVITY
LICENSED CONTRACTORS DECLARATION FLOOR: Br U•' V1611.��"'
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. 00,
License Number Lia Class •� `��� - - •_ -
Contractor Date
i
I 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 $jO ,l
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 /q "y, / =7 0'A5+A
License Law for the following reason (Section ,7031.5, Busi- �`� '-r ""_�' +#,o yo 0 a 0{8
riess and Professions Code): ADDRESST I t
/91 I, as owner of the property, will do the work and the Zr°�° -3 1,!5
structure is not intended or offered for sale (Section CITY rWZATEL. N �+�' � t 1
7044,Business and Professions Code). ' y
OOWNER y�
I, as owner of the property, am exclusively contracting �J!/ �-- 0r4h 2 TJr:8�4
with licensed contractors to construct the project MAIL
(Section 7044, Business and Professions Code). j •ADDRESS _ i
CONSTRUCTION LENDING AGENCY CITY TEL.NO.
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is 1 CONTRACTOR
issued(Sec. 3097,Civ.C.). ;
Lender's Name ADDRESS
Lender's Address CITY TEL.NO. . _ -
I certify that*1 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 Conditioning, and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
County to enter upon the. above-mentioned properly for
in•iection purposes.
S' nature f Permittee Date