HomeMy Public PortalAbout9415 LOWER AZUSA RD_Mechanical__ RS COu1PENSA I'ION D'EC RATION Y ` qq p, �s q s — I "
WOR L.S �1, CE=8T8'(2c$0) 1�'.��s L?� fl I1 4 Ls`C 9' �' .E�` -`"•;• M" `;�.F �.
e �.m'ihat I have a' certificate•o.f consent tq self ,` i r -J°`''•s» 1
ipso.error`•A..?ceiti'filate of Woi•Kers'Compensation Insurance,or :I H' EAT.ING_VE NT•ILATING- I,R 'C®FIDITIOFIOPIG;
p certified copy`i
OIt FRS'COMPENSATION.DECLARATION , . ,: 76A364C. `�} 'I a� ® e�` /� T ' 1 '• '
_..W . _ CE-818(2-$0) Ir�LitI'11 ION `F®t� �PEF�IV�IT.. - ';
I e • , Jm that I have a' certificate of consent to self
i�sdi'es.or�'certifir a of Workers'Compensation Insurance,of ) 14EATING-VENTILATING-Alla CONDITIONING
a certified copyTfigreof(Sec.3800,Lab.C.)
A w y_ .L
Policy No. Company-
0
Certified copy.is hereby furnished.
COUNTY OF,LOS ANGELES BUILDING AND SAFETY
0' Certified copy,is filed with the county building inspection FOR APPLICANT TO FILL IN BUILDING /
department.
Date Applicant (PRINT OR TYPE ONLY) ADDRESS I ,J
CERTIFICATE OF EXEMPTION FROM WORKERS' NO, TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY ! / 7 V
COMPENSATION INSURANCE NEAREST }
e4 f Aa.
•2i- �-
(This section need. not be completed if the work involved . ABSORPTION UNIT; BT CROSS ST. p
by the yermit "is for one hundred dollars ($100) or less.) DISTRICT NO. ROCESSED BY U
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM
permit is issued, I shall not employ any person in any manner CJi tom, O
so as to become8sct to the Workers'Compensation Laws. BOILER, BTU / APPROVALS DATE IIdsFECTO.R S SIGNATUREDate4licant J ( O.
COMPRESSOR,BTU ROUGH N
NOTICE TO APPLICANT: If, after aking this Certificate of Z
VENTILATION SYSTEM FINAL —
E cemption, you should becont subject to the Workers'
Cggnpensat)on provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION
witfi comply with such provisions or this permit shall be
• deemed revoked.
t LICEI4SED CONTRACTORS DECLARATION FLOOR:- FAUB GRAVITY
—
41
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
etfecti.
License Number LiL-Class L� C. 1;r_d
Contractor I-ErAlAf Date
'❑ I am ekempt-from the licensing requirements as I am a
licetised 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 f
Lic.or Reg.No. Date TOTAL FEE 39 1-�S
:HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
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 Code): ADDRESS
1, as owner of the property, will do the work and the TEL.NO.
i structure'is not intended or offered for sale (Section CITY, 7, c
:: a t•.
7044,Business and Professions Code). 11116
�
i❑ OWNER 111PA lfA�
• + I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project MAIL
(Section 7044, Business and Professions Code). ADDRESS ---'-'
CITY TEL.N0. 0.."0 - z r
CONSTRUCTION LENDING AGENCY .,e
1 hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is CONTRACTIOR
issued SSec.3097,Civ.C.).
Lender.s Name ADDRESS /V 4N,Q _-
1" j�•;
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 regulating Heating, Ventilating and
Air Conditioning,and hereby authorize representatives of this I SEE REVERSE FOR EXPLANATORY LANGUAGE
County to enter upon the above-mentioned property for
;iSgiact�uire
on purp sea.o ermittee