HomeMy Public PortalAbout8628 LONGDEN AVE_Mechanical__ 7681 64C � �p �/�
'N61k,:EKS'CgMPENSATION DECLARATION 76 =A3 64 (2-80) /rJ 0C ®V�I FOR P
ERVV T
1 hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers'Compensation Insurance,or HEATING-VENT ILATI NG-Al R CONDITIONING
a certified copy thereof(Sec.3800,Lab.C.) I - U
Polic No. o.Ioth5 Com pan y_IO%f/_7�
Certified copy'is hereby furnished.
COUNTY OF LOS ANGELES BUILDING ARID SAFETY
Certified copy is filed with t'. county building inspection FOR APPLICANT TO FILL IN. BUILDING `
derartme t.
Date= Applica�. (PRINT OR TYPE ONLY) ADDRESS
LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
COMPENSATION INSURANCE NEAREST
(This section need' not be completed if the work involved ABSORPTION UNIT, BTU CROSS ST. d
by the permit is for one hundred dollars ($100) or less.) DISTRICT'NO. PROCESSED aY O
Icertify that in the performance.of the work,for which this AIR HANDLING UNIT,CFM cc is issued, I shall not employ any person in any manner t}_
p
so as to become subject to the Workers'. Compensation Laws. BOILER, BTU
APPROVALS DATE INSPECTO R'S SIGNATURE V
Date Applicant Z d
COMPRESSOR,BTU— Z61M' _ ROUGH
NOTICE TO APPLICANT: If, after making this.Certificate of VENTILATION SYSTEM to
Exemption,. you should become'subject to the Workers' FINAL Z
Compensation provisionsof the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATLON
with comply with such, provisions or this permit 'shall be
deemed revoked.
FURNACE: FAU �1,(�VITY
'LICENSED CONTRACTORS DECLARATION / FLOOR: BTU_�Ls1ly
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 Number ? a Lic,Class ��Q
Contractort. lf_J Date_y""0_{ �4�.
I am exempt'from the licensing..requirements as lam 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 $1/0
Lic.or Reg.No. Date TOTAL FEE
HOME OWN ER-BU ILDER'DECLARATION . PLAN CHECK APPLICANT, :2f6 4 3,8 A
I hereby affirm that I am exempt-from- the Contractor's - NAME # blob a o 8
License Law for the following reason (Section 7031..5, Busi=
ness and Professions Code): ADDRESS 30-5.0
1, as owner of the property,-will do the work and the o 0
CITY TEL. NO. i 0 3 0,5 v
structure is not intended or offered for sale (Section
7044, Business and Professions Code). j
OWNER ��.-Js ^. 0'9,'2'4 82-
1; as owner of the property, am exclusively contracting
with licensed contractors to construct the project MAIL
(Section 7044, Business and Professions Code). ADDRE4+
CONSTRUCTION LENDING AGENCY CITY / L 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.).
Lender's Name ADDRESS
Lender's Address CITY / TEL. NO.
1,certifythat I have read this application and state that the _ /� �
pP STATE LIC. �y _
above information is correct.I agree to'comply with all County LICENSE NO. V �l CLASS
ordinances and State laws regulating Heating, Ventilating and
Air Conditiming,ming,and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE.
Count r enter upon. the above-mentioned property for
insp,.' .�purposes.
S'1, ,turn of Permittee Date =