HomeMy Public PortalAbout9405 PENTLAND ST_Mechanical__ WORKERS that I have a ON DECLARATION CE 81 C APPLICATION FOR PERMIT
1 hereby affirm that 1 have a certificate of Consent to salt
CE 818 (2 80)
Insure or a certificate of Workers Compensation Insurance or HEATING-VENTILATING-AIR CONDITIONING
u ce•tified copythereof(Sec 3800 1 b C^) r`---�,
Poli y No�Otil_1��pany—�\_sem
Certified copy n hereby furnished COUNTY OF LOS ANGELES BUILDING AND SAFETY '
❑ Cernh[,d copy Is filed with the count) building Inspection _ BUILDING
a-partmen• i FOR APPLICANT TO FILL IN
�_\Z�9 p � ��� (PRINT OR TYPE ONLY) ' ADDRESS l ` rc)JCWLJ
Date t bean[_ LOCALITY �+ �/�• t ��
CERTIPICATC OC EXEMPTION PROM 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
by the permit is for one hundred dollars ($100) or less) - DISTRICT NO PROCESsen By_ Qj
1 certify that in the performance of the work for wh eh this AIR HANDLING UNIT CFM _
permit Is Issued I shall not employ any person in any manner + � O
so as to become subject to the Workers Comte+nsatson Laws BOILER BTU H
1 APPROVALS DATE INSP EC/TORR S SIGNATURE W
COMPRESSOR BTU ROUGH ' 9^ 2/' ✓ N
NOTICE TO APPLICANT If after making this Certificate of VENTILATION SYSTEMFINAL Z'ZS- ?
Exemption you should become subject to the Workers '�
Compensation provistons of the Labor Code you must forth EVAPORATIVE COOLER - VALIDATION
with comply with such provisions or this permit shall'he
deemed revoked
FURNACE FAU— ORAVITV -
LICLNSEDCONTRACTORSDECLARATION FLOOR BTU
1 hereby affirm that 1 am licensed under provisions of Chapter HEATER ^ED
9 (commencing with Section 7000)of Division 3 of the Bust ` WALL -
ness and Professions Code and my license is-in-full torte and
effect q �{� p (
License Number agOb� We Class kY\ ^�
Contracto1- f- \ Date�_h=�J_
❑ 1 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-
inns and Professions Code) PERMIT ISSUING FEE $
Lin or Reg No Date TOTAL FEE
HOMEOWNER BUILDER DECLARATION PLAN CHECK APPLICANT
I , `
1 hereby affirm that I am exempt from the Contractor's NAME
License Law for the following reason (Section 7031 5, Busl V moi^
❑ness and Professions Code) - ADDRESS �$ ///'''��
1 as owner of the property will re the work (nil the CITY TEL\r\ TEL NO -->O(�_`_ " r 2 4 4 6 9 A
structure n not Intended or offered for sale Section `-_�- -/`�.`-1` C.��V— -`
7044 Business and Professions Code) — ` '
# S
OWNER
I, as owner of the property,nm exclusively contracting
with licensed contractors to construct the projet,t
MAIL
(Section 7044 Business and Professtons Code) ADDRESS 01, \ l + 2 Q 5 Q\
CIT(,�� TEL NO r� . .'205060
CONSTRUCTION LENDING AGENCY \ r G
1 hereby affirm that there is a construction lending igt.ncy 0 Q 1 2-Pi.3
for the performance of th, ork for which this permit is CONTRACTOR A\I ,., - ���
issued(Sec 3097 Ci C)
Lender s Name _ ADDRESS
Lender s Aildress - CIT'/ \ E( TEL NO
1 certify that I have read this application and state that the STATE �+ \ LIC v-
above Information Is correct 1 agree to comply with all County LICENSE NO CLASS, Qom\
ordinances and State laws regulating Heating Ventilating and ,
Air Conditioning and hereby authon>e representutivLs of this SEL REVERSE I OR EXPLANATORY LAN6UAGE
County to enter upon the above mentioned property for
U'fection L -Dose ' -
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Signature of Permi[leo ^ Date