HomeMy Public PortalAbout9674 LAS TUNAS DR_Mechanical__ • WORPKERS'COMPENSATION DECLARATION CEA 818(2-80) APPLICATION FOR PERMIT
I hereby affirm that I have a' certificak� f consent to self
insure, or a certificate of Workers' Wen Insurance,or HEATING-VENTILATING-AIR CONDITIONING
a certified cop erSeof . i C.)
Poli O/IV -pa
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Certified copy is hereby furnished. d�- J COUNTY OF LOS ANGELE � BUILDING AND SAFETY
Certified copy is filed with the county building inspection
department. FOR APPLICANT TO FILL IN ADDRESS BUILDING C S
Date Applicant (PRINT OR TYPE ONLY)
LOCALITY &'l 7
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
COMPENSATION INSURANCE NEAREST 1�0 .01 �7]
CROSS ST. � �yte�, a
(This section need not be completed if the work involved ABSORPTION UNIT, BTU p
by the permit is for one hundred dollars ($100) or less.) DISTRICT NO. RO Ess BY U
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 manner
so as to become subject to the Workers' Compensation Laws. BOILER, BTUI—
tjf/ APPROVALS DATE INSPECTOR'S S10.1-IRE
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Applicant C w
Date
COMPRESSOR, BTU ��� ��
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NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEMZ
Exemption, you should become subject to the Workers' FINAL
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU GRAVITY ]
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.
License Num//beZ_ Z / Lic.Class C-2-0ContractorG�[/yD—AL,e Date /r L—W
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-
iness and Professions Code). PERMIT ISSUING FEE $
Lic.or Keg.No. Date TOTAL FEE 52`3
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-
ness and Professions Code): ADDRESS
ElI, as owner of the property, will do the work and the CITY TEL. NO.
structure is not intended or offered for sale (Section
7044, Business and Professions Code). o
OWNER y �- 360,3P.
I, as owner of the property, am exclusively contracting = —
with licensed contractors to construct the project MAIL # • • • • (f 1
(Section 7044, Business and Professions Code). ADDRESS
CONSTRUCTION LENDING AGENCY CITY v TEL. NO. 2 • - 2350
I hereby affirm that there is a construction lending agency „ _
for the performance of the work for which this permit is CONTRACTOR T j • • • G 3, ) C'c�
issued(Sec. 3097,Civ.C.). l•¢ 0 1.0 2-8 1
Lender's Name ADDRESS CT ' � Ci
11
Lender's Addressr
- rST
Y TEL. NO.
I certify that I have read this application and state that the ATELIC.
above information is correct.I agree to comply with all County ENSE NO. CLASS
ordinances and State laws regulating Heating, Ventilating and
Air CondiNJ
d hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE.
County tpon the above-mentioned property for
iu ti
'72—
Signature of Permittee Date