HomeMy Public PortalAbout9913 LOWER AZUSA RD_Mechanical__ WO P-KLRS'COMPENSATION DECLARATION 76A3B648C(Z-80) APPLICATION FOR PERMIT
CE-1 4ibreby affirm that I have a certificate of consent to self
insure,or a certificate of Workers'Compensation Insurance,or HEATING-VENTILATING-AIR CONDITIONING
a certifif(Sec 3800,L
CI
Certified copy is hereby furnished I Policy ompaCOUNTY OF LOS ANGELES BUILDING AND SAFETY
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Cq tiff d cog� filed with a co n buil Ing insve ti n BUILDING
FOR APPLICANT TO FILL IN ADDRESS
D te�A
)plica 111: (PRINT OR TYPE ONLY) 'p
LOCALITY
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A TIN
CERTIFICATE OF EXEMP ON FRO WORKERS' NO TYPE OF APPLIANCE OR EQUIPMENT FEE
COMPENSATION INSURANCE NEAREST
(This section need not be completed if the work involved ABSORPTION UNIT,BTU CROSS ST C
by the permit is for one hundred dollars ($100) or less) DISTRICT NO PROC ED BY V
1 certify that in the performance of the work for which this AIR HANDLING UNIT,CFM �. O�
cc
permit is issued, I shall not employ any person in any manner 0
so as to become subject to the Workers' Compensation Laws BOILER,BTU
APPROVALS DATE IN TORSSIGNATURE U
Date Applicant COMPRESSOR BTU
ROUGH d
NOTICE TO APPLICANT If, after making this Certificate of VENTILATION SYSTEM N
Exemption, you should become subject to the Workers' FINAL 2
Compensation provisions of the Labor Code, you must forth EVAPORATIVE COOL R VALIDA ON
with comply with such provisions or this permit shall be
deemed revoked FURNACE FAUST TY �to �
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter HEATER SUSPENDED UNIT
9 (commencing with Section 7 00)of Division 3 of the Busi- WALL
ness and Profess lWo e, an my license is in full force and
effect
License N ber Llc ClanaI I ate
0 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- PERMIT ISSUING FEE $ e
iness and Professions Code) V 'e
Lic or Reg No Date TOTAL FEE
fl-
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT . i t t3
1 hereby affirm that I am exempt from the Contractor's NAME - 20 a 5
License Law for the following reason (Section 7031 5, Busi-
ness and Professions Code) ADDRESS
0 I, as owner of the property, will d0 the work and the CITY TEL NO �' - '`C
structure is not Intended or offered for sale (Section
` 7044,Business and Professions Code) —MMI
OWNERMLQU
13 1, as owner of the property, am exclusively contracting
with licensed contractors to construct the project MAIL DO
(Section 7044,Business and Professions Code) ADDRA 1 j{r 4P m U),ya<
CONSTRUCTION LENDING AGENCY CIT TEL •
I hereby affirm that there is a construction lending agency R
for the performance of the work for which this permit is
issued OSec 3097,Civ C)
Lender s Name S
Lender's Address CoTEL
I certify that I have read his application and state that the STA E CLASS J
above information is coir I agree to comply with all County 1
ordinances and State la regulating Heating, Ventilating and
Air Conditioning,and h by authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
Count to ent upo the above- entioned property r
Ins io p set
S gna i—eof Perini t a Date