HomeMy Public PortalAbout5549 NOEL DR_Mechanical__ WUR KLRS COMPENSATION DECLARATii l CEA 3619',1280) APPLICATION FOR PERMIT
I herebv affirm that 1 haves a certificate of conswit to self
insure or a certificate nt Workers jComQnsation Insurance or HEATING-VENTILATING-AIR CONDITIONING '
a certified fop) thereof(Sec 3800Policv No Company_
Certiticd copy is hereby furnisned COUNTY OF LOS ANGELES IL ING AFE
Certifjed cop) is filed with the c untAddi inspection FOR APPLICANT TO FILL IN BUILDING `s
ileo%r#me r ADDRESS
DateApplicant_ _ _ (PRINT OR TV PE ONLY)
LOCALITY
CLRTII ICATE OF EXEMPTION FROM WORKEi �' NO TYPE OF APPLIANCE 09 EQUIPMENT FEE
COMPENSATION INSURANCE NEAREST
(TMS section need not be completed if the work involved ABSORPTION UNIT BTU CROSS ST d
b) the permit is for one hundred dollars (5100) or less) DISTRICT NO PROCESS BY V
1 ee.rtity that in the performance of the work for which this AIR HANDLING UNIT CFM
permit is issued, I %hall not employ any person in any manner W
so as to become subject to the Workers Compensation Laws BOILER BTU i.1
APPROVALS DATE INSPECTOR S SIGNATURE
Date Applicantr
COMPRESSOR BTU ROUGH O.
NOTICE TO APPLICANT If atter making this Certificate of VENTILATION SYSTEMFINAL Z
Exemption _ you should become subject 'n the Worker-,
Compensation provisions of the Labor Code you mus, forth EVAPORATIVE COOLER VALIDATION
with comph with such piovisions or this permit shall be
deemed revoked FURNACE F Aii GRAVITY
LiCFNSIi CONTRACTORS DECLARATION FLOOR BTU
I hcrcny -affirm that I am licensed under provisions of Chaptt,r HEATER SUSPENDED UNIT
9 (commencing with Section 7000) of Division 3 of the Bust r WALL .�)
ne-s and Profesbtons Code and my license is in frill Force and -
effect V4;Z1-,1
License Nu ��Lic Class C jo
Contrictur_ DateI am , e ucensing 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
Ines%and Profcg%tons Code) PERMIT ISSUING FEES `
Lic or Reg No Date I TOTAL FEE
HOMEOWNER B JILDi R.DECLARATION PLAN CHECK APPLICANT
I hereby affirm that i am exempt from the Contractors NAME r;,9t4 3.7 A
I icensc Law for the following reason (Section 7031 5 Bust
ne-s and Professions Codi.) ADDRESS #,• •`• • • 8
Q1 as owner of the property will do the work and the CITY 2r• 0 2 i
structure, is not intended or offered for %tie (Section TEL NO 5 `
7044 Business and Professions Code) ,
❑ OWNER ' f•r• • 2 0'5 025
I as owner of the property am exclusively contracting
with licensed contractors to construct the project MAIL
ADDRESS `�J/ – 01 28-83
_
Section 7044 Business and Professions Code) �ISS �J 7
CONSTRUCI ION LLNDING AGLNCY CITY / TEL NO aPj� /
I hereby iffirm that theie is t construction lending agency – --
for the performance of the work for which CONTRACT
this permit is _
issued(Sec 3097 Civ C,) – —
Lender s Name ADDRESS
Lender b Address CITY / TEL NO
i certify that i have read this application and state that the STATE _ LIC G.�
above Inform ttion is correct i agree to comply with all County LICENSE NO ./ CLASS d
ordmdnccs and Stdte laws rcgul itmg seating Ventilating and
Air %-onditioninf, ind hereby authorize representatives of this SEL REVERSE FOR EXPLANATORY LANGUAGE.
County to enter upon he above mentioned property for
VtnjrpQ1'e nittee !/