HomeMy Public PortalAbout9538 LIVE OAK AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION CEA 8 8 (2.80) d= Il—� P L4�IC AT�O �I FOR PERM IT
I hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers'Compensation Insurance,or HEATING-VENTILATING-AIR CC)N®ITIC)NIN�i
a certified copy thereof(Sec 3840,Lab.C) ,
Policy No.-. Company COUNTY OF LOS ANGELES ' �' BUILDING ARID SAFETY
Certified copy is hereby furnished
Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN BUILDING Q
department „(
Date Applicant (PRINT OR TYPE ONLY) ADDRESS
LOCALITY �
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT � FEE
COMPENSATION INSURANCE NEAREST >_
CROSS ST ,�- ` d
--(This section need not be completed if the work involved ABSORPTION UNIT, BTU p
by•the permit is For ore hundred dollars ($100) oI less.) DISTRICT NO PROCE c BY
I certify that in the performance of the rk for which this AIR HANDLING UNIT,CFM 5,d r/ a
permit is issued, I shall riot employ any .son in manner' d O
so as to become subject to the WorS Comr ,is^..on Laws BOILER, BTU
.�I APPROVALS DATE INSPECTOR'S SIGNATURE, W
COMPRESSOR,BTU
ROUGH
NOTICE TO APPLICANT: If, arter ,nakirig this Certifi ate of VENTILATION SYSTEM S _ Z
Exemption, you should betom subject to the Workers' FINAL —
Compen'sation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION
with comply with Such provisions or this permit shall be
deemed revoked.
LICENSED CONTRACTORS DECLARATION FLOOR. FAUBTU GRAVITY �3
I hereby affirm that i am licensed under provisions of Chapter HEATER _ DED UNIT
9 (eommegcing with Section 7000) of Division 3 of the Busi- ` WALL
ness and Professions Code, and my license is in full force and TQe/oar
effect. ' � W
License Number �Lic.Class
,T_ - •
Coniractor�t���'-L C.►(I'y�0ate_'�f ��—$ �”- .
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 $ Q
Lic"or Reg.No. Date TOTAL FEE 3 SD
HOME OWNER-BUMDER DECLARATION PLAN CHECK APPLICA
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 Codt) ADDRESS
O1, as owner of the property, will do the work and the
structure is not intended or offered for sale,(Section CITY TEL" O.
7044, Businegs and Professions Code)
I, as owner of the property, am exclusive) OWNER 23.713,3•A
p p y, y•cantractmg
with licensed contractors to construct the project AMAIL DDRESS I:
00,o.o 0.8
(Section 7044, Business and Professions Code)
a
CONSTRUCTION LENDING AGENCY CITY TEL NO, -21-!-'23,50
I hereby affirm that there is a construction lending agency /
for the performance of the work for which this permit is CONTRACTOR _!/�67ct(r L� S f- 10' 2 3 5 0 c=i
issued ESec. 3097,Civ,C.), • I t
Lender s Name ADDRESS 1 /� ��r//p �o 2�6'-82
Lender's Address
CITY �=/ //` TEL NO Y�7
I certify that I have read this application and state that the STATE / 4 LIC.
above inforri ,r is correct.I agree to comply with all County LICENSE NO D�� CLASS
ordinances a d tate laws regulating Heating, Ventilating and
Air Condi+"on`�g, and hereby authortze representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
County enter upon +' c ovv mentioned property for _
tnspe '-•- .pun.
.,' ,Iatur,of} mitt Date