HomeMy Public PortalAbout9241 KENNERLY ST_Mechanical__ WORKERS'COMPENSATION DECLARATION 76A364C- .
I hereby affirm that I have a' certificate of :onsent to self CE 818 (2-80) If 'L���s/�a� �.Ytl ®� l�UIS UVU ��;
insure,or a certificate of'Workers'Compensation Insurance,of HEATING-VENTILATING-AIR GOND ITIONING
a certified copy thereof(Sec. 3800,Lab. C.)
Pott ified copy is hereby'furnished.
;CertrtiCOUNTY'OF•LOS ANGELES BUILDING ARID SAFETY
Certified copy is filed with the county building inspectionF BUILDING
department. FOR APPLICANT TO FILL IN
Date Applicant, (PRINT OR TYPE ONLY) ADDRESS `_
LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NO, TYPE OF APPLIANCE OR EQUIPMENT FEE.
COMPENSATION INSURANCECROSS ST. 0-
(This,section need not be completed-.it the work involved ABSORPTION UNIT, BTU
by the permit is for.one hundred dollars ($100) or,less.) DISTRICT NO PROCESSED BY 0
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 manner0' O
so as to become subject'to•the Workers' Compensation Laws. BOILER, BTU -
Q 77 ♦,"� APPROVALS- DATE INSPECTOR'S SIGNATURE U-
Dat��g_2'J(�Appticant�c�r✓F-x�.�X��G.-(�,� t11
COMPRESSOR,-BTU ROUGH "� _ �
NOTICE TO APPLICANT: If, after tnaking-this Certif'icat'e of VENTILATION SYSTEMFINAL �Z—Z— z
.Exemption, you should become subject to the Workers'-
'Compensation provisions of.tlle Labor Code, you must forth- -EVAPORATIVE COOLER, `VALIDATION
with. comply, with such •provisions or this permit shall be
deemed revoked.'.
'LICENSED CONTRACTORS DECLARATION FURNACE: FAU GRAVITY
FLOOR: BTU
Thereby affirm that I am licensed under.provisions of Chapter HEATER: SUSPENDED UNIT
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. � ��( Z
License Nuniberc�GF10__1'_ Lic. Class v
Contracto ,_JVr,__�3U._ Date
I am exempt from the licgnsing 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-
iness and Professions Code). PERMIT ISSUING FEE $
Lic.or Reg.No. Date TOTALTEE
-HOME OWNER-BUILDER DE,CLARATION:' PLAN CHECK`APPLICANT' - -
I hereby affirm that T amexempt_ from- the Contractor's -NAME
License•Law for the following reason (Section. 7031.5, Busi-
ness and Professions Code): ADDRESS
0 1, 'as owner of the property, will do•the-work'and theme
' 15'9'0,'2,A '
structure is not intended or offered for sale (Section CITY ' - TEL. NO.�GZ} j H
7044, Business and Professions Code). r• #$se o .o .0 0,$
OWNER,) ^�� /
- •O I, as owner of the-property, am exclusively contracting 4�Jfil+t�5 � - •' "- 2.0•l0 � 16;�.0;ti
with licensed contractors to construct - the ' project MAIL' v<-
(Section 7044, Business and Professions Code). ADDRESA2A I•
I
CONSTRUCTION LENDING AGENCY CITl'i1.%' '`�=�J 'TEL.N.O.
A hereby affirm that there,'is'a construction lending agency
for the performance of-the'work for which this permit,is ` CONTRACTOR
issued(Sec. 3097,'Civ.'C.). — -
Lender's Name ADDRESS?
Lender's Address CITY TEL..NO,��/tri !
I certify that I have read this application and state that the STATE LIC.''
abs t_,formation is correct.l agree to comply with all County LICENSE MO.� CLASS
or 'Banc'" and State laws regulating Heating, Ventilating and -
A%.at , 'toning, a--dherebyauthorize representatives of this' SEE REVERSE-POR•EXPLANATORY.LANGUAGEante' u ion the above-mentioned properly for ure of Permittee D2te ;