HomeMy Public PortalAbout10253 RANDWICK DR_Mechanical__ WORKJERS'COMPENSATION DECLARATION i CEA 8 8(2-80) A P P L� CAT 0®II�1 FOR PER 11711 T
I hereby affirm that I have a• certificate of consent to self
insure,or a certificate of Workers'Compensation Insurance,or H EATING-V ENTILATIIVG-AIR CONDITIONING
tif' o y they f(� 38 ^ L .x
-- 'oj any "c%
Certified copy is hereby furnis ed. COUNTY OF LOS ANGELES DING ®SA
sCerCertified copy is filed with the county buitdtttg-i specti n i BUILDING
t 777FO:RAPPLICANTTO FILL INDate�ftld Applicants...` • RINT OR TYPE ONLY) ADDRESS
I LOCALITY �•
CERTIFICATE 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. a
by the permit is for one hundred dollars ($100) or less.) DISTRICT NO. PROCESSED Y t U
1 certify that in the performance of the work for which this I AIR HANDLING UNIT,CFM
permit is issued, I shall not employ any person in any manner 6 / d 1,
so as t become subject to the Worke o sation Laws. i BOILER,BTU O
,/�` \ i APPROVALS DATE INSPECTOR'S SIGNATURE 1-
Da Applica tri ` \1`�-- COMPRESSOR BTU. 'ROUGH a
NOTICL TO APPLICANT: If, after making this Certificate ofa r N
VENTILATION SYSTEM
Exemption, you should become subject to the Workers' FINAL i e
Compensation provisions of the Labor Code, you must forth- ' EVAPORATIVE COOLER VALIDATION
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION F OR: BTU
I hereby affirm that I am licensed under provisions of Chapter 'I HEATER SUSPENDED UNIT ; 2r
9 (commencing with Section 7000)of Division 3 of the Busi- WALL
ness and Professions Code, and my license is in full force andq O
effect. I a[
License NumberIC.Class
cora .orte l
I am exempt from the licensing requirements as I am a ,
licensed architect or a registered professional engineer Plan check fee 25%of above.
acting in my professional capacity (Section 7051, Bus PERMIT ISSUING FEE$-
iness and Professions Code).
Lic.or Reg.No. Date TOTAL FEE
HOME OWNER-BUILDER DECLARAT ON 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 work and the CITY TEL.
structure is not intended or offered for sale (Section �,
7044, Business and Professions Code).
O OWNE 243A,7A
I, asowner of the property, am exclusively contracting
with licensed contractors to construct the project MAIL # 4
(Section 7044,Business and Professions Code). I ADDRES o 0 0 0
CONSTRUCTION LENDING AGENCY CITY ` NO• 2 - -.27.00
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is CONTRACTOR . o - 27.006
issued(Sec.3097,Civ.C.). I (7 1- 0-81
1 0—8 1
Lender's Name ADDRES
Lender's Address CITY ._7 - TEL.NO.
I certify that I have read this application and state that the STATE LIC.
above information is correct.I agree.to comply with all County LICENSE.NO. CLASS
Ordinances and State laws regulating Heating, Ventilating and,
Air Conditioning, and hereby authorize representatives of this' SEE REVERSE FOR EXPLANATORY LANGUAGE
my to enter upon the above-mentioned property tori
ins ction purposes. .�
gnature of Permittee Date