HomeMy Public PortalAbout9614 LOWER AZUSA RD_Mechanical__ WORKERS•COMPENSATIONDECLARATION CE 81C APPLICATION FOR PERMIT
�L I hereby affirm that I. have a' certificate of consent to self CE 878 (2-80)
insure, ocertificate Workers'Compensation Insurance,or HEATING-VENTILATING-AIR CONDITIONING
a certifiedd c copy thereof(Sec. 3800,Lab.C.) v
Policy No. Company
Certified copy is.hereby furnished.
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN BUILDING
department. ADDRESS
Date Applicant (PRINT OR TYPE ONLY) tt
LOCALITY :r L f 1
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE ( e
COMPENSATION INSURANCE NEAREST T"CROSS$T. Y� i ( 1 r ('� ��' A 41 � CL
CL
(This section need not be completed if the work involved ABSORPTION UNIT, BTU
by the permit is for one hundred dollars (S`IOO) or less.) DISTRICT NO. PROCEsstSD s U
'I certify that in the performance of the work for whic this AIR HANDLING UNIT,CFM W
J
permit is issued, I shall not employ an.X person �t LL
so as to become subject to the Wopk6�"(� 0_eiris t aw BOILER, BTU
•.�+�• _ �l/ ,(,: APPROVALS DATE INSPECTOR'S SIGNATURE }
Date i `}Applicant t C dib'` 1
r
COMPRESSOR, BTU ROUGH
NOTICE TO APPLICANT:If, after making this Certificate of VENTILATION SYSTEM
Exemption, you shouldFINAL become subject to the Workers' d
Compensation provisions of the Labor Code, you must forth-
with comply with"such provisions or this permit shall be
deemed revoked. FURNACE: FAU GRAVITY j� I—
LICENSED CONTRACTORS DECLARATION FLOOR BTU - 6
I hereby affirm that I am licensed under provisions of Chapter HEATER: SUSPENDED UNIT f
9 (commencing with Section 7000)of Division 3 of the Busi- WA
ness and Professions Code, and my license is in full force and
effect.
J�
License Numbrr- '" � � Lie.Class–
Contractor-
1.
lassContractorI.am exempt from the.licensing requirements as I am a
licensed architect or a registered professional engineer Pian check fee 25% Of above.
acting in my professional capacity (Section 7051, Bus-
iness and ProfessionsCode).w. PERMIT ISSUING FEE $
Lie.or Reg.No. Date TOTAL FEE
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- ry
ness'and Professions Code): ADDRESS ' A
1, as owner of the property, will do the work and the
structure 'is not-intended or offered for sale (Section CITY TEL. NO.
` 7044, Business and professions Code). y Ii i
ffOWNER
I, as owner of the property,'am exclusively contracting IS
4 with licensed contractorsto construct the project MAIL , "
(Section 7044, Business and Professions Code). ADDRESS y�
4►4 "
CONSTRUCTION LENDING AGENCY CITY TEL. NO.
I hereby affirm that there is a Construction l6ding agency «. sLr�y ,
for the performance of the work for which this permit is ro ONTRACTOR
issued(Sec. 3097,Civ.C.).
Lender's Name ADDRESS
Lender's Address CITY' '. .`o ^Y' r' <( TEL. NO.
I certify that I have read this application and state that theSTATE „ �f 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 SEE REVERSE FOR EXPLANATORY LANGUAGE
County to enter t1 f,above-mentioned .property for
J+r�P4c purpos.
Signature of Permittee Date