Loading...
HomeMy Public PortalAbout9803 GARIBALDI AVE_Mechanical__ f h NO t%--RS'COMPENSATION DECLARATION CEA 88 P"�18 (2-80) f P L�C AT I O 1�7 FOR !!—E R ICY T ,-�by affirm that I have r certificate of consent to self '0$lite, or a certificate of Workers'Compensation Insurance,o'r HEATING-VENTILATING-AIR CONDITIONING .`s`certl vy t f c. 3800,Lab.C. D Polls mpany r ' Certified copy Ig hereby furnished' COUNTY OF LOS ANGELES �s�J � BUILDING ARID SAFETY Certlfled copy Is flied with the county bui;;G ]on art ant. �y� FOR APPLICANT TO FILL IN BUI LDING Data Applicant (PRINT OR,TYPE ONLYI ADDE{ESS LOCALITY CERTIF'ICAT-E OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT. FEE COMPENSATION INSURANCFr {NEAREST ' (This rection need not be completed tf the work hnohed ABSORPTION UNIT, BTU GROSS ST. by the permit is -for one hundLed doilan (5100) br lem) DISTRICT NO. PROCESSED BY 8 I certify that in the performance of the work for which this AIR HANDLING UNIT CFM O permit fs issued;I shall not employ any peon In any manner Q to as to become'subject to the,Worken' Compensation Laws. BOILER, BTU APPROVALS DATE INS?E=FI'3 SIGhIATURE Date E Applicant CQMPRF SSOR BTU �d lL ROUGH N©TICE TO APPLICANT: If, after making thisCertiflcite of VENTIhATION SYSTEM FINAL Z Exemption, you should become subject to the Workers Compensation provisions of the Labor Code, you must forth- With comply with such provisions or this permit shall, be EVAPORATIVE COOLER VALIDATION deemed-revpked. FU RN4CE1 FAU IT LICENSED CONTRACTORS DECLAR kTION FLOOR;_ BT �d I hereby affb-m that I am Ilcefued urrder provtsiptU of Chapter- HEAT]-Ff. SUSPENP5D UNIT 9 (commencing with,Sectlon 7000) of-Division 3 of ttm Busi- WALL. nees and Professions Code, end my license Is In full force and effect. License Number. Lia Clga : Contractor .•Data_ ;21 26.6A -a•1 am exempt from the HaJnsing requlr -writs as I am a - # ° • • ° • 8 llcenied architect or a iegiitered profeutonal.eniineer Plan Check foe 25%of above. acting In my professional capacity (Section•7051, Bus- 2;e • 2 /,0 0 Iness and Profesalons Code). PERMIT ISSUING FEE$ O O 25 Llc.or Reg.No. Data TOTAL FEE pQ ;o a,• 2 0 HOMir OWNER-BUILDER DECLARATION PLAN CHECK,APPLICANT 0 9.2 1 -&.1 f hereby .afflr n:that I ■m gxempt from- the Contractor's NAME C VZ License Law for the following reason (Section 1031.5, Bush nese and Professions Code} ADDRESS CV 3 f 1, as owner of the property, will do the work and the structure Is not intonded or offered for sale (Section CIT TEL. N 7044, Business and Professions Code). • !//�J/f . I, as ownbr of the property, am exclusively contracting .OWNkR V ' •'�`� with. licensed contractors to construct the project MAIL (Section 7044, Business and Profaulow Code). ADDRESS- CONSTRUCTION LENDING AGENCY CITY"J EL.NO. I hereby affirm that there is a construction lending agency for the perfoFFpp��ance of the work for wplcb this permit is CONTRACTKR C issued Sec. 3U97,Cir.C.). , Lender s Name' ADDRESS r Lender'sAddress /� TEL. NO CITY ,_12/ 1 certify that I have read this application and state that the STAT LIC. above Information Is correct.I agree to comply with all County CLA 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 luspec 'n purQp� ����� CJ7/ Signatureof Permittee Data