HomeMy Public PortalAbout5533 NOEL DR_Mechanical__ WORKLRS COMPENSATION DECLARATION CEA 8 a(Z BG) APPLICATION FOR PERMIT
1 hereby affirm that I hate a certificate of consent to self
insure or a certificate of Workers'Compensation Insurance or HEATING-VENTILATING-AIR CONDITIONING
a certified copy thereof(Sec 3800 Lab C)
t PolicyNy-_� / ant— COUNTY OF LOS ANGELES BUILDING AND SAFETY
f ertified cops is hereby furnished
Certified copy is filed with th ounts II Ing inspection FOR APPLICANT TO FILL IN BUILDING
depart en /' ? 7
Dat p �I Applicant (PRINT OR TYPE ONLY) ADDRESS
@ % y� LOCALITY Tc -
CERTIFICATE OF EXLMPTION FROM WORKERS NO TYPE OF APPLIANCE OR EQUIPMENT FEE
COMPENSATION INSURANCE NEAREST
CROSS ST �/�� or 4e-� >-
(This section need not be completed if the work involved ABSORPTION UNIT BTU a
by the permit is for one hundred dollars (5100) or less) Q;�fO DISTRICT NO PROCESSED Y U
I certify that in the performance of the work for which this AIR H N NG UNIT CFM
permit is Issued I shall not employ any person in any manner 6., e �
so is to become subject to the Workers Compensation Laws BOILER BTU O
APPROVALS 4ATE "INSPECTORS SIGN TURE V
Date Applicant COMPRESSOR BTU tJJ
ROUGH
NOTICE TO APPLICANT If after making this Certificate of VENTILATION SYSTEM r z
Exemption you should become subject to the Workers FINAL ?
Compensation prosisions of the Labor Code you must fortis EVAPORATIVE COOLER VALIDATION
with comply with such provisions or this permit shall be _
deemed resoked FURNACE FAU V GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I herebv affirm that 1 am licensed under provisions of Chapter HEATER SUSPENDED UN IT
9 (commencing with Section 7000)of Division 3 of the Busi WALL do'OG
nets and Professions Lode and my license is in full force and
effect �16
License Numbet'� Lic Class_
Contracta 6 ' ,eta Date 3
I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer EPlancheck fee 25%of above
acting in my professional Lapacity (Section 7051 Bus PERMIT ISSUING FEE $ SO
iness and Professions Code)
Lic or Reg No Date TOTAL FEE S� r
HOME OWNER BUILDER DLCLARATION PLAN CHECK APPLICANT,
1 herebv affirm that I am exempt from the Contractor's NAME -�
License Law for the follow,ng reason (Section 7031 5 Bust
ness and Professions Code) ADDRESS 71 0C s r/t./N S�,G��'v
I as owner of the propertl will do the work and the /
structure is not intended or offered for sale (Section CITY
sTEL NOa 7�L�p
7044 Business and Professions Code)
❑ OWNER d �►—
I as owner of the property, am exclusively contracting /� ��2 9 3 A
with licensed contractors to construct tiie project ADDRESS��3� Qom/ ✓
(Section 7044 Business and Professions Code) # 8
CONSTRUCTION LENDING AGENCY CITY T'C- TEL NO 2'•,• 4f 8 5 0
I herebs affirm that there its d construction lending agency CONTRACTOR
for the performance of the work for which this permit is
issued(Sec 3097 Cn C) '• • • 4 8 5 0
Lender s Name ADDRESS 710E Sv�dN' C� ��� ,
50
Lender s Address CITY TEL NO 0316-82
I certify th it I have read this application and state that the STATE �/ 9;V LIC
above information is correct I agree to comply with all County [LICENSE NO `7' —� CLASS `
ordinances and State IawS regulating Hoatutg Ventilating and
Air Conditioning and herebl authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
Goun to enter rupon the, above mentioned 7(Y
ty for
mss n o s /
gnature o ermittee Ll�erDate