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Home My Public Portal About10635 HALLWOOD DR_Mechanical__ W&KERS'COMPENSATION DECLARATION //pp�� np � ((gi�pp FOR n2n/�/� h/4— or I hereby affirm that I have a certificate of consent to self /r P LS�CG�1��O� N COQ PERM?insure, or a certificate of Workers' Compensation Insurance, 76A364C HEATING - VENTILATING - AIR CONDITIONING a certified copy thereof (Sec. 3800,'Lab.-C.) �i ❑ 818(REV. 10/81) ;- Policy No.IOd yo Company L� Fa4ld Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY Certified copy is.filed with the countybuilding,inspec- FOR APPLICANT TO FILL IN BUILDING /� tion department. ADDRESS �®Cf��S �AL (PRINT OR TYPE,ONLY) . Date Pd� �7 �7Applicant LOCALITY NO.. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST y�� G COMPENSATION INSURANCE CROSS ST. (- (This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO. PROCESSED the permit is for one hundred dollars($100)or less.), —� AIR HANDLING UNIT, CFM I ceriify that in the performance of the work for which this t permit is issued, I shall not employany,person in any-manner so as to become subject to the Workers'Compensation Laws. BOILER, BTU /�) APPROVALS DATE INSPECT 'S Date Applicant SIG ATUR COMPRESSOR,_ BTU 3 6 & /J(J V O ROUGH i L ^ NOTICE TO APPLICANT: If,- after making this Certificate of VENTILATION SYSTEM FINAL U Exemption, you should become subject.to the 'Workers' Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATICN with comply with such provisions or this permit shall be deemed-revoked. FURNACE: FAU GRAVITY LICENSED CONTRACTORS DECLARATION FLOOR BTU I hereby ciffirm that I am licensed'under provisions of Chapter 9 HEATER: SUSPENDED UNIT(cornWALLmencing-with Section 7000) of Division 3 of the Business � and Professions Code,and my license is in full force and effect. " 1fi_ 2 .O� 6`Tv V u License Number Lic. Class L 0 D Contractor '- CO" SA Date / f1 ,-7 O u I am exempt under Sec. Iw Plan check fee CL N B.&P.C. for this reason Z PERMIT ISSUING FEE $' 7 D Signature �' t � � TOTAL FEE z 8 9..7 A OWNER-BUILDER DECLARATIIZW PLAN CHECK APPLICANT # o io o o a 8 I hereby affirm that I am exempt from the Contractor's License Do'0 5 2 5 Low for the following'reason (Section 7031:5, Business and NAME -Professions Code):- o oro 532550 ❑ I, as owner of the property, or my employees with ADDRESS wages as their sole compensation,will do the work and CITY TEL. NO. 9 9 1 -87 the structure'is not intended or offered for sale(Section 7044,Business and Professions Code). ^� OWNER /r �S T I•Z /'�y/�/iY �/O ❑ I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec- MAIL. j tion 7044, Business and Professions Code). ADDRESS .l0(0 3 S f7`{ 11' vOod .D I CONSTRUCTION LENDING AGENCY CITY'' _T c TEL. NO. I hereby affirm that there is a construction lending agency for D the performance of the work for which this permit is issued ' CONTRACTOR (Sec. 3097, Civ. C.).-J';q,W4J J � e/NAS �Lender's Namel?I/ ADDRESS cyJ D� fjlP Lender's Address 3 ///�-�/�� 0 CITY OS p�?/�� TEL. NO.��Ip I certifythat I have read this application and state that the STATE / J v UC. A-- above O pp LICENSE NO. �//�O � -CLASS - 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-abo -menti 191property for_inspecti n purposes._ SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or AEVI. Date - "