HomeMy Public PortalAbout9663-9665 LAS TUNAS DR_Mechanical__ 111*1
e WpRKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
I hese/' affirm that I have a certificate of consent to self
ins i ora copyca erof Wo(Srke s'Oo Lab 76A364C
certifinssation Insurance, HEATING - VENTILATING - AIR CONDITIONING
rfleCE-818(REV. 10/811
Policy No. Company
Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with the county buil Ing inspec- FOR APPLICANT TO FILL IN BUILDING r 7Z
tion department. ADDRESS �cO� lG!/L/.�,5
(PRINT OR TYPE ONLY)
Date 7 Applicant LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE s
CERTIFICATE OF EXEMPT•ON FROM 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 hundred dollars($100)or less.)
AIR HANDLING UNIT,CFM
I certify that in the performance of the work for which this J C/
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers"Compensation Laws. / BOILER,BTU APPROVALS DATE I PECTOR'S SIGN TORE
Date Applicant ! COMPRESSOR, BTU 24,, MIN ROUGH
Ay
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- -EVAPORATIVE COOLER VALIDATION
with comply with such provisions or this permit shall be
deemed revoked. /' FURNACE: FAU CyIT
LICENSED CONTRACTORS DECLARATION r FLOOR BTU J�
I hereby affirm that I am licensed under provisions of Chapter 9HEATER: SUSPENDED UNIT
`(commencing with Section 7000) of Division 3 of the Business WALL
and Professions Code,and my license is in full-force and effect.
License Number 43 2— Lic. Clasa_ V
�7 fll / wndatl /�S!!�T , 6
Contractor ate G 0
❑ I am exempt under Sec. g 4 Q 7 A esa
Plan check fee a
B.BP.C. for this reason' �r # o a o o�o
PERMIT ISSUING FEE$ (J
Date:
Signature TOTAL FEE aj(J. 1 -,- 3(150
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT a a a 3 a 5 0 x6
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and NAME
/.Q��—S
Professions Code): 1 1,20-87
El1, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and CI / TEL. NO pow
the structure is not intended or offered for sale(Section TY ��ig O rr7
7044, Business and Professions Code). /J
OWNER ���I
❑ I,'as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec- MAIL
ADDRESS
tion 7044, Business and Professions Code).
.CONSTRUCTION LENDING AGENCY CITY TEL.
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued CONTRACTOR 0
(Sec. 3097, Civ. C.).
ADDRESS
Lender's Name
CITY TEL. NO.
Lender's AddressTATE C�
I certify that I have read this application and state that the LICENSE N030/2,0 Z CLASSe—JQ—
above i ormation is correct. I agree to comply with all County
ordina s and St to laws relating to building construction,
and eby rize representatives of this County to enter
upo the a mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
`l Z�-V? ,
ignature of plicant or Agent Date