HomeMy Public PortalAbout9925 LAS TUNAS DR_Mechanical__ 0MPENSATION DECLARATION 76A364C �j ^ �p
,? CE 818 (2-80), AFFIL CATH ON FOR ���.Mff
I'hiergby a`ti:m2 That I have a' certifleate of:Qnseut to self
insu*i, qr a cei-Mcate of Workers'Compensation Insurance,or HEATING-VENTILATING-AIR CONDITIONING
a certified crpvs-r--f(See 3800,Lab.C.) 1..1
Poi y Nof Company�QP
K _ ;
a Certified copy is tiereby futai�hed:• f' COUNTY OF LOS ANGELES BUILDING AND SAFETY .
��Certifietieopy is filed with the county Building inspection z BUILDING
deirirtme rt , (j FOR APPLICANT TO FILL IN .ADDRESS_ .3
r ��,��-}- ess�y (PRINT OR'TYPE ONLY)
gate_ oZ� APPiicant_LC `
L,O CSA L I T V
CEgTIF CATE OF EXEMPT70N FROM WORKERS' NO. , •TYPE OFtlAPPL-IANCE OR EQUIPMENT FEE
fytiMPEN$AT1()N INSURANCE NEAREST•} „
(This_.gection-beed not be completed'if the work involved ABSORPTION UNIT, BTU• CROSS ST .�
by the_pettnit-is.kor-one hundred dollars ($100) or less.) DISTRICT.NO PROCESS BY' ', t �� "0
I certrfy''Lh�t lq 11�e pgr6 mance,of the work for which this AI-R HANDLING UNIT;CFM
' 'Permit-is'ftued,`I shall not employ any per$o�.n in any manner = - 0
so us to ltecome'sub}ect to the Workeri''Compensation Laws. BOILER, BTU C
APPROVALS DATE INSPEC R'S SIGNAT RE *_�•-'
Date- „ .'- ftp t> ant CQMPRESSOR,BTU_�QO ROUGH f W
En
NOTICE TO APPLICANT• If, after-making-this Certificate of - . VENTILATION SYSTEM 11 'o FINAL I Z'
Eseiaption, you should becorpe subject to the'-Workers' — -
' Compensation-orovistons of tha Eabor Code; yod must forth- l f
: EVAPORATIVE COOLER VALID— ION
with comply with suCh pfovisions or.this permit shall .be a r -
deemedredok-ed =t- r. FURNACE: FAU GR'AVITY�
LICENSEDCbNTRACTORSI�L`CLA•R�TION FLOOR BTU
'I hereby affirm that F arr licensed under provisions',of Chapter HEATER 'SUSPENDED _ UNIT
9-(commeneing with Section 7000)of Dnis}on•3 of-the Busl-- WALL v
ness ant Professions Code,Ud my license is-in full force"and
effect. -
License Nurm�-beer �/
Li..Class.C" �, 7:S,1.A
Contraetorrl51C tY1C 'Datela� J e`e3_e' 7 a
I amexempt -from t he licensirig requirements as I am a =� -
licensed architect or a registexed'ptofissional engineer Plan check fee 25%,of above., ;'�.e e 3 Q 5 0 `
acting in-my -professional Capacity (Section 7051, Bias o PERMIT-ISSUING•FEE $
mess and Professions Code}. x = _
laic or Reg,No. Date (TOTAL FEE ° ! 3(1'5
0
HOME d"ER-BViLbER DECLARATION PLAN CHECK'APPLICANT
03127-85
''I hereby affirm that l epi ezetnpt',f,;om-,the-Contractor's NAME "`. ..
License Law for'the followmg reason'(Section 7031:5•, Bus)- '
ness and PFofessions•Code): ADDRESS
I, aS-owner of the propdxty, will do-the work and the
--structure i;' not intended or offerdd for-sale (Section CITY TEL NO
7044, Business and krofessions Code).
- _ QWNER,_ � -
Q,I, as owner of the*pi•operty,.am exclusively contracting -
with ]icertsed contractors to construct {Iie. project MAIL r� r^ �, ft,
(Section 7044,Business`sad IPYofessiomi Code). ADDRESS- _� °f✓'o=Lf1�S'�L<N145 _
• .
" CONSTRUCTIOD[ LENDING AGVNCY CITY_ �' TEL NO.J�'J�,-C� �'', , • �'" -
I• hereby affirm that there is a construction lending agency -. - , ti, - � - •�- _for, the performance of the work for which this permit is CONTRACTOR C
'issucd0ec,.3097;Civ.C)
Tendei,s_Name ADDRESS
Lender's Addr@ss CITY' s , c� TEL.NO
certify that I have read this application and sate that the STATE ��� L'IC at1�
above information is correct.1 agree to comply with all County LICENSE NO. oZ eZ-76 CLASS Cio'�p
- ordinances and State laws regulating.Heating, Ventilating and
Air Conditioning,and hereby authorize-representatives of this 'SEE REVERSE FOR EXPLANATORY LANGUAGE -
County
��too enter-Upon the above-mentioned property for
ty
Signature 6f Permittee Date '