HomeMy Public PortalAbout8802 HERMOSA DR_Mechanical__ DEC
TION
WORKERS' Ihave COMPENSATION cafe of corse APPLICATION FOR PERMIT
I hereby affirm that I have a certificate of consent to self '
insure, or a certificate of Workers' Compensation Insurance, ]bA364C HEATING -VENTILATING - AIR CONDITIONING
or a certified copy thereof (Sec 3800, Lab. C.) CE 818(REV. 10/81) -
Policy No.-Company
Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
• ❑ Certified copy is filed with the county building,inspec- FOR APPLICANT TO FILL IN BUILDING G
C n
tion department. (PRINT OR TYPE ONLY) ADDRESS ..�/
Date Applicant LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE ROSS ST.
(This section.need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT No. RROCESSED BY
the permit is for one hundred dollars ($100)or less.) -
'I certify that in the performance of the work for which this AIR HANDLING UNIT, CFM
permit is issued, I shall not employ any person in any manne,f
so as to become BOILER, BTU_ ome subject t�lhe Wor Co n G ipp Lays ( nvPRovats Dnte INSPECTOR'S SIGNATURE
Date
Applicon
�CJ_o j COMPRESSOR, BTU ROUGH
Dat
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL R
Exemption, you should become subject to the Workers'
Compensation provisions of the Lobar Code, you must forth- EVAPORATIVE COOLER - VALIDATION
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR 8Tu_Z0_9,,0o v
Id
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT_
(commencing with Section 7000) of Division 3 of the Business HEATER: WALL
and Professions Code, and my license is in full force and effect. }
si
O
License Number Lit. Class ► V
OC
Contractor Date - 0
❑ I am exempt under Sec. ssVs
Plan check fee N
Dote:
B.BP.C. for this reason us
ISSUING FEES d ,$v z
Signature TOTAL FEE O SO
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License ►
Law for the following reason (Section 7031.5, Business and NAME
Professions Code):
❑ I, as owner of the property, or my employees with ADDRESS '2 01 919 A
wages as their sole compensation,will do the work and
the structure is not intended or offered for sale(Section 111TY .� TEL. NO. # e a o e e 8
7044, Business and Professions Code). '
❑ OWNER / 220.50
I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec- MAILADDRESS2 0.5 0
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY (k—8 3•
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued CONTRACTOR
(Sec. 3097, Civ. C.). -
ADDRESS '
Lender's Name
CITY TEL. NO _
Lender's Address
STATE LIC.
I certify that I have read this application and state that the LICENSE NO. CLASS
above information is correct. I agree 10 comply with all County
ordinances and State laws relating to building construction,
and he a horize represent9 fives of this County to enter
OR
ih e-iA gone pr ¢e rY r inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
�Signatme of Applicant ar Agof Applicant ar Agent —� v Date