HomeMy Public PortalAbout9160 LAS TUNAS DR_Mechanical__ s��`.�.WORKERS' COMPENSAItUN ULCLAW_A-TIOr� 76A364C
I WORKERS
affirm that I have a' certificate of.consent to self CE -816 (2-80) APPLICATION FOR PERMIT
insure, or a certificate of Workers'Compensation Insurance,or HEATING-VENTILATING-AIR CONDITIONING
a certified cop thereof(Sec. 3800,Lab. )
Pdlicy Noi "' ''t w �yny'— = ,_s •-;�
C rtified copy is hereby furnished.
COUNTY OF LOS ANGELES UILDING AND SAFETY
rtified copy is filed with the county building inspection FOR APPLICANT TO FI WIN UILDING
Car!"
ti'a� '•"e�R-1
Applicant r`1)"(A l tW (PRINT OR TYPE ON Y) ADDRESS p
r'
LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' Nfj�ta
O. TYPE OF APPLIANCE OR FQU NT FEE
COMPENSATION INSURANCE NEAREST d
(This section need n be co: ted if the work involved ABSORPTION UNIT, BTU CROSS ST. (,
by the permit is f6t" to htrt Veddollars ($IOU) Or less.) ti' DISTRICT NO. PROCESSED BY L)
' -
I certify that in the performance of the work for which this AIR HANDLING UN IT,CF 7 lL r _I
permit is issued, I shall not emplby any person in any manner LL
so as to become subject to the Workers'Com pensation.Laws. BOILER, BTU Is
- r, - APPROVALS DATE - INSPECTOR'S SIGNATURE }
Date Applicant COMPRESSOR, BTU Cr
ROUGH Q
NOTICE TO APPLICANT: If, after making this Certified-Te of (VENTILATION SYSTEMcc
Exemption, you should become subject to the Workers' FINAL a
.Compensation provisions of the Labor Code, you must forth- *tr
with comply with .such provisions or this permit shall he EVAPORATIVE COOLER :;.w VALIDATION 2
deemed revoked. - W
FURNACE: FAU GRAVITY I-
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby 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. �� i` C.,
License NumberC. Lic.Class L" _
# r'
Contractor ,ILII f.j 10 1 i t sxr'+ Date --
ElI 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- r-
inessand Profe ssions Code). PERMIT ISSUING FEE $
Lic.or Reg.No. Date,_ TOTAL FEE 1 �
r •
HOME OWNER-BUILDF..R/DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I:am exempt from- the Contr'actor's NAME
License Law for the following reason'(Section 7031.5 Busi- -------- -
ness and Professions Code): ADDRESS
I, as owner of the property, will do the work and the CITY TEL. NO.
structure Js not intended or offered for sale (Section
7044,Business and Professions Code). -— ------
OI, as owner of the property, aril exclusively contt�icting OWNER_._
with licensed contractors to construct the project MAIL ± c_
CC (Section"704,0;Business and Professions Code), ADDRESS
f'
i ! t-', } R t'
CONSTRUCTION LP:NDING AG$NCY CITY TEL.NO.��.,
I 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.). - t
Lender's Name _ ADDRESS 1U 1L
Lender's Address { l-
CITY y ; ,. 1 TEL. NO. —4-i" -I
I certify that I have read this application and state titat the STATE /' LIC. k _{
above information is correct!)agree to comply with all County ii LICENSE NO. CLASS
ordinances and State laws regulating Heating, Ventilating and
Air Gonditioning,"and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
County :to enter+ upon:the above-mentioned ;property for
inspection ourp*ls, a
Signature of Permittee Date