HomeMy Public PortalAbout10755 LYNROSE ST_Mechanical__ WORKERS'COMPENSATION DIVLARATION 76A364C LA lid fid p �� A O®(gyp f�®[i�f IZ IIS(�/1 ��
I hcrehy affirm that I have a' certificate of consent to self ; CE-818(2 80) A Imo,, If— l_ A p�I FOR E ITS 1711
inure,or a certificate of Workers'Compensation Insurance,or HEATING-VENTILATING-AIR CONDITIONING
a t 'rt led co th reo (Sr .3 00,Lab.C.)
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u is o y
Certified copy is hereby furnished. ! COUNTY OF LOS ANGELES ' BUILDING AND SAFETY
❑ Certified copy is filed with cou t building inspectio FOR APPLICANT TO FILL IN BUILDING
D;itd Applicant ^ (PRINT OR TYPE ONLY) ADDRESS��
I i LOCALITY t
ERTI ICATE OF EXEMPTION FROM WORKERS' NO TYPE OF APPLIANCE OR EQUIPMENT FEE
COMPENSATION INSURANCE I NEAREST _
(This section need not be completed if the work involved ABSORPTION UNIT, BTU CROSS ST. _
by the permit is for one hundred dollars ($100) or less.) DISTRICT NO PROCESSEDAY r
I c:rtify 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 �.t"l� 00%
so :is to become subject to the Workers'Compensation laws. BOILER,BTU
APPROVALS DATE INSPECTOR'S SIGNATURE W
Dat. Applicant (COMPRESSOR,BTU ROUGH N
N01 ICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL e �—
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code,you must forth- EVAPORATIVE COOLER VALIDATION
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I Itereby 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
et-t"ct.
License Nummbe Lic. lass
Contractaf a1 �
❑ I am exempt from the licensing req irements •s I an 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).
1 ic,or Reg.No. Date TOTAL FEE 3
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
❑ I, as owner of the property, will do the «ork and the TEL.NO.
structure is not intended or offered for sale (Section CITY
7044,Business and Professions Code). (OW9 4 14
NER n
❑ r
I, as owner of the property, am exclusively contracting I 11 0 0 0 0 0
with licensed contractors to construct the project MAL
(Section 7044, Business and Professions Code). AD: RESS } 2 0 0 1 3.0c
CIT
TEL NO. 7Q $74
CONSTRUCTION LENDING AGENCY '- o , ^_
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is CONTRACT �^,p
in,ued(Sec.3097,Civ.C.). — J�( 4
Lender's Name ADDRESS
9
An
Lender's Address y CITY TEL.NO
I certify that I have read this application and state that the STA E LIC.
above information is correct.I agree to comply with all County LICENSE NO. CLASS
ordinances and State laws regulating Heating, Ventilating and
Nir Conditioning,and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGF
County to enter upon the above-mentioned property for
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