HomeMy Public PortalAbout9437 KENNERLY ST_Mechanical__ WORKERS'COMPENSATION DECLARATION CEA S SC(2-80) G G�UC A T�O�I FOR E'�UVU U
I hereby affirm that I have a certificate of consent to self
inure, or a certificate'of Workers'Compensation•Insurance,or 'M(EATING-VENTILATING-AI Rd CONDITIONING•,,
a certified copy thereof(��j�3800,Lab.C.)
Policy N6 1A�f I'ml�'any GST—/� Al/
CpUNTY OF,LOS ANGELES BUILDING AND.SAFETY
� Certified copy is hereby furnished. '- '°
Certified copy is filed with the county building inspectionBUILDING s `
❑"'department. 'FOR APPLICANT TO'FIL•LIN , ADDRESS �j7 wwE�Ct y
Date Applicant, (PRINT OR TYPE ONLY)
LOCALITY r?nhL ,C�
CERTIFICATE OF,-EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT," FEE
COMPENSATION INSURANCE NEAREST }
CROSS ST. C�����LL d
(This,section-need not be.completed, if,the.wABSORPTION UNIT,,involved U
by the permit is for one hundred dollars ($100)'or"less.) DISTRICT NO. PROCESSED BY
•1 certify•that'in the,performance of the".work,for which this AIR HANDLING,UNIT,CFM O�
,permit is issued, I shall not employ any person in any manner O
so•as to become subject to the.Worker's' Compensation Laws. 1 BOILER, BTU
-APPROVALS DATE INSPECTOR'S SIGNATURE (�
a W .
aLlate Applicant COMPRESSOR;BTU TROUGH 23^ N -
NOTICE,TO APPLICANT:-If, after making-,this Certificate of VENTILATION SYSTEM, FINAL ' Z'.
,Exemption, you ,should become subject•to ' the'•Workers' "'" '
Compensation provisions,of the Labor Code, you must forth
with;•comply-with such-provisi'o•'ns or- this permit shall be EVAPORATIVE COOLER, s -VALIDATION ;
deemed revoked. " ' FURNACE: FAU-' GRAVITY
—
FA
DECLARATION '- FLO 0 URNA BTU
I hereby affirm'that,I am'licensed under:provisions ofChapter HEATER, S DED- UNIT
9' (commencing with Section'7000) of:Division- 3 of the Busi- . L
ness and Professions Code, and my license'is iri full'force and — c
effect. oZJ 4bG 67V -
License Number Lic..Class —
Contractor Date
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 myo professional capacity (Section 7051', Bus-' `' :4:7 rJ 1'A•
iness and Professions Code). PERMIT.ISSUING FEE $`a
Lie.or Reg.No. r' Date TOTAL FEE' _ G.Q V. 8
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT �.0' ,,O, it 8
'1' hereby, 'affirm that-I am, exempt from- the Contractor's NAME.
License Law,for.the following reason (Section 7031.5, Busi=
_ 1 i t
nes;and`ProfessionsCode): ADDRESS, # o o^0 0
t q
❑ 1, as owner of the pioperty,'will do the*'tivork'and the "
' CITY- "' TEL. NO.T- 2'o to 3 0,.5.0
structure is not intended, or offered for "sale (Section '
7044, Business and Professions Code). �:
x OWNER' oo o,3Fo'5 0.', 5,'
D, 1, as owner of the property, am the the
`.
--with licensed contractors,,to"construct -,the piojec"t - MAIL ' 0.•
,(Section 7044, Business arid,Professions Code). ADDRESS
CONSTRUCTION LENDING AGENCY CITY -'TEL. NO. -
I hereby affirm,that there isa construction lending agency
for the performance of the work for which this permit is CONTRACTOR' _
issued-(Sec. 3097;Civ.C.).
Lend'er's Name A'DDRESS'.
Lender's Address CITY TEL. NO_ _
1 certify that I have read this application and state that the STATE• LIC•-'
above information is•correct..l agree to comply with all County LICENSE NO." CLASS
,ordinances and State laws.regulating-Heating".Ventilating and
Air Conditionin ,and.her'e6y authorize representatives of this'.. SEE REVERSE"FOR•EXPLANATORY LANGUAGE
County to (er upon,sp tih ove-mentioned properly f9r
io rposes'
ature of Permittee Date