HomeMy Public PortalAbout9632 LONGDEN AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION �— 7' A364C"-'
I hereby affirm that I have a'certificate of consent to self CE-:818(2-80) APPLICATION F;O R PERMIT '
insure, or a certificate of Workers'Compensation Insurance,oc HEATING-VENTILATING-AIR CONDITIONING
a certified copy-.thereof(Sec.3800,Lab.C.)
Policy rti Company
—
E] Certified copy is hereby furnished. COUNTY OF LOS ANGELES T ' BUILDING AND SAFETY
❑ Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN BUILDING /_ •� n-yl 41) `o
department. 63a
Date Applicant. (PRINT OR TYPE ONLY) ADDRESS
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TLOCALITY TIM ��, i
' TYPE OF:APPLIANCE OR EQUIPMENT FEE 1.
COMPENSATION INSURANCE NEAREST .�^� K }
(This section -need not be completed if the Work involved ABSORPTION UNIT,BTU CROSS ST. / — o/ 191v-0- C
• by the permit is for. one 'liabdred dollars ($100) or 'less.) DISTRICT NO: PR CESSE BY �. 0
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM
permit is issued,NI shall not employ any person in any manner f ��
so as to become subject to the Workers'Compensation Laws. BOILER,BTU
APPROVALS DATE INSPECTOR'S SIGNATURE IJJ
Date Applicant 'COMPRESSOR,BTU ROUGH CL
N
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM
Exemption., you should become subject to the Workers' FINAL •I?^
Compensation provision's of the Labor Code,you must forth- EVAPORATIVE COOLER VALIDATION
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU V T
•LICENSED CONTRACTORS DECLARATION FLOOR: BTU
I hereby:affirm that-I am licensed under•provisions of Chapter HEATER: •SUSPENDED UNIT
9 (commencing with-Section 7000)of Division 3 of the Busi- WALL
ness and Professions'Code, and my license is in full force and
effect.
License Number Ltc.Class
Contractor Date
PI am. exempt from the:licensing requirements as I am a
licensed archifeci' or a•registered professional. engineer Plan check.fee 25%of above. ,
acting in my professional capacity (Section 7051, Bus-
iness and-Professions Code). PERMIT ISSUING FEE$
Lic,or Reg.No. Date TOTAL FEE ;
1`IOME OWNER-BUILDER DECLARATION _ [CITY
LAN CHECK APPLICANT
I'hereby.,affvm ,that .I am exempt from .the.Contractor's AME JAI
License L`aw for the following reason (Section 70.3.1.5, Busi-
ness and Professions Code): DDRESS, 2 �Q
I, as owner of the property, will do the work.and the 2.4 2.6 6 A.
structure is not intended or offered for sale (Section �j f EL.NO.
7044,Business and Professions Code). `� -9 p�
OWNER � C 'o 0 0. o
'I, as owner of the property;am exclusively contracting '
with licensed contractors to construct the project MAIL . 2 o o .4 Z 0 0.
(Section 7044,Business and,Professions Code). ADDRESS
• CONSTRUCTION LENDING AGENCY CITY 1D(.A TEL.NO. 7—� 0 0 0.47.00'
I hereby affirm that there is a construction lending agency 03,02-81
YY
for the performance of the;work for which this permit is CONTRACTOR OWN �
issued Tec. 3097,Civ.C.),
Lender s Name ADDRESS ` O UL r0i e
it
I Lender's Address .CITY TEL.NO.
I certify that I have read this application and state that the STATE LIC.
above information is correct.I agree to comply with all County LICENSE NO. CLASS
ordinances and State laws regulatinging, Ventilating and
Air Conditioning,and hereby utho ' e presentatives of this �i SEE REVERSE FOR EXPLANATORY LANGUAGE
Count o. e r u b tinned property for
i� ect' ose
natur of Permitt Date _