HomeMy Public PortalAbout9941 HOWLAND DR_Mechanical__ WORKERS'COMPENSATION DECL'kRATION 76A364C A
I hereby affirm that I have a certificate 1f,consent to self CE-818 (2-60) G �1 If- if L�Q�(rel II�l �O UIS L�l(1S�Vll��
insure,or a certificate of Workers'Compensation Insurance,or HEATING-VENT IL•ATINGi_AlR CONDOTIONI1`I G
a certifi►►ep c-�y t�e,V*?'z c. 3800. Lab.C.)
Policy No� �R lc�npany lc
Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUI WING.AND SAFETY
Certified copy is filed with the county building inpe- ion BUILDING
14
de artm,ni? ! FOR APPLICANT TO FILL IN 3
Date�p Z� �Applicant, < _ _�_ t (PRINT OR TYPE ONLY.) ADDRESS r >��fa►�%�
RP
• � LOCALITY V� /J�,-� �.l^r y
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
COMPENSATION INSURANCE NEAREST }
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(This section need not be completed if the work involved ABSORPTION UNIT, BTU CROSS ST. 0 LI _ O
by the permit is for one hundred dollars ($100) or less.) DISTRICT NO. PROCESSEQ By O
1`c'ertify that in the performance of the work for which this AIR HANDLING UNIT,CFM- /, �/ CC
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permit is issued"I shall not employ any person in any manner (J a
so as to become subject to the WW1, 11' Compensa'ion .ws. BOILER, BTU: F_
3 APPROVALS . DATE INSPECTOR' IGNATURE U
Date4i/1= .�ApPlicant ��i ,)_ /' LU
COMPRESSOR, BTU Uri O a ROUGH
NOTICE TO AP.PLICANT:'If, after making this Certificate of ( VENTILATION SYSTEM Z
V FINAL
Exemption, you .'should become subject to the Workers'
Compensation provisions of the.Labor Code, you must forth- EVAPORATIVE COOLED VALIDATION
with'comply with such provisions or this permit.'shall be
deemed revoked. FURNACE: FAU r RAVITY ,_ �—
LICENSED CONTRACTQRS DECLAR ATION t FLOOR:
I hereby affirm that 1 am licensed under provisions of Chapter HEATER: SUSPENDED UNIT
9 (commencing with Section 7000)of Division 3 of the Busi- WALL
ness and ProfessionsCode, and my license is in full force and �e!
effect. t
License Number.34-5_5�l/ Lic.Class
Contractor06opY(r Date_z��� O
El1 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-
mess and Professions Code). PERMIT ISSUING FEE $ � �f
Lic.or Keg.No. Date - TOTAL FEE 1>1'7 J�
HOMEOWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm thlt 1, am exempt from- the Contractor's NAME
License Law for the-following reason (Section 7031.5, Busi-
ness and Professions Code): ADDRESS
1, as owner of the property, will do the work and the
structure is 'not intended or .offered for.sale (Section CITY TEL. NO.
7.044, Business and Professions Code).
QOWNER ✓Y/ (�
I, as owner of the property, am exclusively_contracting,t !with licensed contractors to construct the project MAIL ,� z'4 0.4,5 A
(Section 7044, Business and Professions.Ctide). ADDRESS • �
CITY �r TEL. NO. � #.o
CONSTRUCTION LENDING AGENCY
1' hereby affirm that there is.,a construction lending agency
for the performance of the work.-for which this permit is CONTRACTORe� �! N- j �' �� 2 ° ° 2 7+'0 0
issued Sec.'3097,Civ.C.).
Lender.s Name ADDRESS e'C�C" ' j� •O'° ° 2 7;0 0 cz�
Lender's Address CITY TEL.NO. C j .O 2. 1 1 —8 1
I certify that I have read this application and state that the STATE LIC.
above information is correct.I agree to comply with all County LICENSE NO. y 3 ` GLASSY
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 tha ah,ie-mentioned properly for t
inspectior
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`C:gnature ofofPerntittee date
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