HomeMy Public PortalAbout9814 GARIBALDI AVE_Mechanical__ WSR�ERS'CQMPENSATION DECLARATION 7BA364C _
I hereby affirmthat I have if certificate of consent.to self CE -818 (2-80) APPLICATION FOR PERMIT
insure, or a certificate-of Workers'Compensation Insurance,or . HEATING-VENTILATING-AIR CONDITIONING
a certffied copy thereof(Sec. 3800, Lab.C)
Policy No.—Company
COUNTY OF LOS lANGELE BUILDING AND SAFETY El copy is hereby furnished. . �
Cartifled copy;b filed with the county building InspectionB
department. FOR APPLICANT•TO FI LL IN 41LDIt1P y,
Date Applicant (PRINT OR TYPE ONLY) ADDRESS �Ct+
,
LOCALITY
CERTIFICATE QF EXEMPTION"FRbZ.I WWORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FFHE
COMPENSATION IN�VRANCE NEAREST
CROSS ST.. d
(This section need_ not be fated if the Wort tr"tyed ABSORPTION UNIT, BTU
by the permit is for one htu►dred dollari (5100) or lea.) - DISTRICT NO. - R
I certify that In thl performaBce of the work for which this AIR HAN.IDLING UNIT CF �
permit It{cued, I shall not employ any person In any manner
so as to become subject to the Wdrken' Compersatloq Laws. BOILE9, BTU
APPROVALS. RATE IWECTOR•$ "-YuRE
LU .
Date Appllcagt COMPRESSOR BTU - 16 ROUGH
-
NOTICt:TO APPLICANT: If, after maktng this Certificate of ����
`/FNTILATION SY§'TEM FINAL - �k du
Exemption, you should become subject' to the Workers'
Compensation provisions of She Labor Coda, you must forth- EVAPORATIVE COOLER VALIDATION
with co�ply with such provisions or this, permit shall be
deemed revdked. -FURNACE:, ,FA U NP
O k Y
' LICENSED CONTRACTORS DECLARATION FLOOR: —
, 16
I hereby affirm that Iam licensed under-provlslonsof Chapter HEATER:-- SU8PENDEI3 UNIT _
9 (commencing with Section 7000) of Dtvlsion 3'of the Buil- WALL
neas and Professions Code, and my license Is in full-4orce and
effect_ 17 414 _ -
Llcense Nummbei� ic.Coss, C"I"10
Contracforl'J IWk -17 64051]iate
❑ I am exempt from the licensing requirements',y I ■m a "
Hcensed architect or ■ registered professional'ongineer Plan ckleck.fee 25%of-above. -
acting In my professlonil capacity. (Section 7QSI, Bus-
iness and Professions,Code). PERMIT ISSUING FEE
Lic.or Reg.No. Date TOTAL FEE
HOME OWNER-BUILDER DECLARATIO
K 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-'
nese and Professions Code): ADI?R
❑ I, ty
w owner. of the'proper , wQl da the work and the 7J 1 9.2
stracturo Is not Intended or offered for aIle (Section CITY TEL.NO. _
I 7044, Business and Professions Code). # •r• • • 4
OANER
F ❑ I,,ff.owner of the prdparty, "am exclusively contracting " • • 2 h d
pu
With licensed- -contractors to construct thh _pToject MAIL
(Section 7044, Business and Professions Code). ADD-RESS
CITY' TEL.NO. is • • 2471 0 0 65
CONSTRUCTION LENDING-AGENCY Q
I hereby affirm that there -is ' construction lending agency
CONTRACTOR 4—�1
for the performance oqf the'•Work for winch this.permit it
issued SSec. 3097,Civ.
C
'Lender s Name ) ADDRESS
Lender's Address CITY TE L.NO.
I certify,that I have read this applicatipn and state that the STATE LIC_
above information is correct.I agree to comply with sit County ICEN74- CLASS
ordinances and State laws regulating Heating, VaRtllating and
AU Conditioning, and hereby authorize representattves of this SEE REVERSE FOR EXPLANATORY LANGUAGE
County, to enter upon the above-ment nod p perty for
lnay}pt
f .
Slgnatureo ruittee Dho _.