Loading...
HomeMy Public PortalAbout10109 LANDSEER ST_Mechanical__ WORKERS'COMPENSATION DECLARATION 76A364C /� pp �p p p� /, (� np (� �/� I hereby affirm that I have•a certificate of consent ;r� self CE-818 (2-$0)' !r-�1�•� ��/?,\�0®� ®U,S l� LS II�/Il �� ' insure, or a certificate of Workers'Compensation Insurance,or HiEATIWGM�WTIL�TING-AIR1' CONDITIONING a certified copy thereof(Sec. 3800, Lab.-C.) Policy No. Company T E Certified copy�s hereby furnished.' COUNTY OF LOS ANGELES ^ ,"r BUILDING AND SAFETY n•-.Certified copy is filed with the county building inspection department. FOR APPLICANT TO FILL IN'" BUiLDIivG Date Applicant (PRINT OR TYPE"ONLY) ADDRESS - v .LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS"- NO. TYPE OF„APPLIANCE OR-EQUIPMENT - FEE--~' COMPENSATION INSURANCE` NEAREST. } CROSS ST. ' (This.�sectlon need not be completed if the work involved ABSORPTION UNIT, BTU m"� 0 by the permit is for one hundred doilars'($100) OI less.) DISTRICT NO PROGESSE BY- 0 a I certify that in 'the performance of ttie work.for which this 'Al R HANDLING UNIT,CF-M permit'is issued, I shall not employ any person in any manner A �� i CJj O so as to become subject to the W r ersCompensation aws. BOILER, BTU— APPROVALS G-� APPROVALS DATE INSPECTOR'S SIGNATURE Applicant /� - COMPRESSOR, BTU . ROUGH — . d OUG ��.� Z to NOTICE TO APPLICANT: If, after makin chis Certificate'of 1/ENTIL'ATION`SYSTEMZ' Exenription, you should -become subject.'to the* Workers' FIIV•AL' Compensation'provisions of the Labor Code, you-musf forth- EVAPORATIVE'COOLER VALIDATION with comply with such provisions or' this permit shalll;be deemed revoked. FURNACE: FAU GRAV,IT.Y LICENSED CONTRACTORS DECLARATION ' FLOOR: BTU' 'T I'hereby affirm that I am licensed under provisions of Chaptei HEATER: 'SUSPENDED UNIT 9 '(commencing with Section ,7000) of Division 3'of the Busi- WALL ness and Profession's Code, and my license is in full-force and effect. License Number' -.Lic.-Class . Contractor Date h am exempt from the'licensing requirements as I am a licensed architect or a registered- professional engineer `Plan Check fee 25%.of above. acting in my professional capacity (Section 7051; Bus- iness and Professions Code). PERMIT ISSUING FEE$ S� Lic.or Reg.No. Date " TOTAL FEE HOME OWNER-BUILDER DECLARATION' PLAN CHECK APPLICANT I hereby •affirm.that I am,exempt from,- the 'Contractor's f NAME License Law for the following reason (Section 7031.5, Busi- e ' ness and Professions Code): ADDRESS�Q�© �S�d� I, as'owner of the.property,will do:the work and the P ' CITY /J TEL. NO. (�,7 7,Q A„ structure is •noi'intended or`offered.'for.�sale (Section ��j/�LC'�/jf�(� ��_ 7044, Business and Professions Code). " ' - , " /— �j��/ �/ - ` OWNER• ,�/ . �I�'L - # o .o�o•o o'8 IXI I, as owner of the property, am exclusively contiacting /"G /� / < t .i> 4, ,• with licensed contractors, to construct ttle� project MAIL (Section 7044, Business ind Professions Code) ADDRESS A2/0 /2/ �/� 2 0�o 11 `6 5 0 CITY TEL.NO. o C{o 1 ;6,°5 0 CONSTRUCTION LENDING AGENCY �EiUf�G� ��� I hereby"affirm' that there is a construction.lending agency — 1 for the.performance of the work for which this permit is CON-TRACTOR ,�'�,<7 6 8 2 k/i_�/�Z' SLG ;ai ,>�rT.. issued(Sec.3097,-Civ.C.):-. Lender's.Name ADDRESS Lender's Address- CITY TEL.-NO. _ 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: CLASS ; ordinarices and State laws regulating Heating, Ventilating and Air Conditioning,and hereby authorize representatives of,this SEE REVERSE FOR EXPLANATORY LANGUAGE COunt� , enter r' on tie above-mention/ed//property for ❑lS /n'/.f•� r+ ature of Permittr a ,'. at -