HomeMy Public PortalAbout9226 KENNERLY ST_Mechanical__ C
WORKERS'COMPENSATION D'CLARATION CE 818 (2-80) A P P UC n T�®N - F®R PERM
I hereby affirm" that I have a' certi date of consent to self - c� 1
insure,or a certificate of Workers' mpensation Insurance,or HEATING-VENT IL.AT IWG-AIR CONDITIONING , U
a certified copy thereof(Sec. 380 ,Lab.C.)
Policy No. Compa i
❑ Certified copy is hereby/urriished.- ...COUNTY OF LOS-;ANGELES •- -BUILDING AND SAFETY
❑ Certified copy is filecj wiih the county building inspecfion BUILDING n
department. FOR APPLICANTTO'FILL^IN ' ADDRESs
Date ' App rcant `(PRINT OR TYPE ONLY) e.
LOCALITY_faPM7 et
CERTIFICATE O 'E)CtMPTIONFROM'WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT,, FEE Y =
COMPENSATION INSURANCE NEAREST t zl�4?c }
(This section.need not'be completed_if the work involved ABSORPTION_UN)T: BTU CROSS ST. Q��Y O
z
by the permit Js for one hundred,dollars'($100) or less.) DISTRICT'NO. PROCESSED BY (�
I certify that in the performance of the work for which this AIR HANDLIN"G UNIT,CFM"
X.
permit is issued, I shall not employ any person in'any manner - �� O
so as to become'subject to the Workers' Compensation Laws. BOILER,BTU '
• APPROVALS; DATE INSPECTOR'S SIGNATURE (�
Datc -Applicant _ — .. �� COMPRESSOR, BTU ROUGH y
^� —� Z
NOTICE'TO APPLICANT: If, after•making this Certificate of .. VENTIL'ATION'SYSTEM 77
Exemption, you should become subject to the Workers', FINAL-.
rCompensation provisions,of the Labor Code, you must forth; - EVAPORATIVE COOLER' VAL.I'DATION
with' domply with- such' provisions dr this permit shall be
deemed revoked. Dai
FURNACE:- -FAU�J� GRAVITY -
LICENSEDCONTRACTORSD'ECLARATION FLOOR:` BTU F/6_1 �7� f
I hereby affirm that I am licensed under-provisionsof'Chapter' H'EA-TE`R-: •SUSPEN,DED UNIT, r /� V Z5
9 (commencing with Section 7000) of Division 3 of the'•Busi, WALL
ness and Professions Code, and my license.is in=•full force and
effect. G
License Number-. 3Lic.Class_— 9_`i
Contractor e Date ,� r -
❑ I 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- PERMIT ISSUING FEE $
iness and Professions Code). a.
Lic.or Reg.No: Date TOTAL FEE r.
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT ,
I hereby affirm -that I am exempt from- the Contractor's NAME
License Law for the following reason-(Section 7031.5,'Busi- �.4;6:9., {�
ness.and Professioris Code): ADDRESS s
❑-i, as,owner of the property, will do the work and the # 0 8
structure is not intended or offered for-sale- (Section CITY = STEL. NO.
•7044,''Business and Professions Code). _a
❑ OWNER wV'��1i�! [' �.V C�' t ` . _ .
I, as.owner of'the, property, am exclusively contracting, !;.0,3'a
i,•
with licensed' contractors to construct the project ' MAIL s• ;oro•o`3.a'5 0`�.
(Section 7044, Business and Professions Code).. ADDRESS 2 _k � `•
CONSTRUCTION LENDING AGENCY-. CITY�Gy/1r�J t Lf TEL•. NO'. ' g���g$��' +
I hereby affirm that there is a'construction'lending agency' ✓- -
for the 'performance of the work for which this permit is CONTRACTOR - m� A i GQ ?� r:
issued (Sec. 3097„Civ.
C.). •.
Lender's Name ADDRESS ” t
Lender's Address TEL.NO: c� Ll _ , �i"• 4.
CITY` t rI7'C1//��! J o ��
I certify that I hive read this application and state that the; ' STATE LIC:
above information is correct. I agre'e'to comply with all County LICENSE NO. 7� CLASS G :2
'ordinances and State laws regulating.Heating,,-Ventilating*.and r
Air Conditioning, and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE"
County to,e ter up n the ab mentioned property for
inspection pu
Signat re f Permi .ee B Date Y ,