HomeMy Public PortalAbout9537 LAS TUNAS DR_Mechanical__ _)KSS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
I hereb�affirm that I have a certificate of consent to self
insure, or a certificate of Workers'Compensation Insurance, . HEATING - VENTILATING - AIR CONDITIONING
p��a�ecectrf' d �q Taj re (iec. 3800, Lab. C.) 76A364C
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La , . CE -818(REV. 0/81)
Policy No. .. Company
Certified copy is hereby furnished.Aa
. COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING ��
ADDRESS 5 ny Ci s V A aS
ti n department. (PRINT OR TYPE ONLY)
tOCAL1T r_
Date Applican a r /..
NO. TYPE OF APPLIANCE OR EQUIPMENT - FEE
CERTIFICATE OF EXEMPTION FRO WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST.
(This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO. PROCESSED BY
the permit is for one hundied dollars ($100)or less.)
AIR HANDLING UNIT, CFM
c
I certify that in the performance of The work for which this .. ,
.permit is issued, I shall not employ any person in any manner BOILER, BTU
so as to become subject to the Workers'.Compensation Laws. APPROVALS DATE PECTOR'S SIGNATURE
/�
COMPRESSOR, BTU V (J oROUGH ,
Date Applicant
NOTICE TO APPLICANT: If, after making' this'Certificote of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers' 011
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATI N
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 9 HEATER: SUSPENDED UNIT
(commencing with Section 7000) of Division 3 of the Business WALL
and Professions Code, and my license is in full force and effect. >
L'cen se Num er�)0 (. Lic. Class
Contractor Date ' O•'
❑ I am exempt under Sec. cfii 2 5 9 5 A U
Plan check fee
B.&P.C. for this reasonH
PERMIT ISSUING FEE $ ko'o o o o 8
Date:
Signature TOTAL FEE I.0 - 20,50
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License � 0 0 o 2 Q 5 0,P
-
Law for the following reason (Section 7031.5, Business and NAME
-Professions Code) c 8 Q 6-8 5
❑ 1, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and
the structure is not intended or offered for sale(Section CITY TEL. NO..
7044, Business and Professions Code).
'
El 1, as owner of the property, am exclusively contracting OWNERS
with licensed contractors to construct the'project (Sec- MAIL ��CC
tion 7044, Business and Professions Code). ADDRESS Ju f �1 trL `
CONSTRUCTION LENDING AGENCYCITY `y TEL. NO.
I hereby affirm that there is a construction lending agency for• C4N
the performance of the work for which this permit is issued CONTRACTOR
(Sec. 3097, Civ..C.). ;A ' -
ADDRESS f(� ® fq►
Lender's Name 9
CITYCQJ f1 I, TEL. NO. Jy�_/ 11
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Lender's Address 6
STATE C� `� e LIC.
I certify that I have read this application and state that the LICENSE NO. �) Y CLASS
above information is correct. I agree to comply with all County
ordinances and State laws relating to building construction,
and hereb authorize representatives of this County to enter
po e Dove-menti ned property for ir'sp coon purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE,
Signature of Ap Iicant or Agent Date - - - - - - -