HomeMy Public PortalAbout9202 ROSEGLEN ST_Mechanical__ WORKV*RS'COMPENSATION DECLARATION CE 81 C APPLICATION
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I hereby affirm that I have a' certificate of consent to self CE-81 B (2 80) Fri L IC P`i 1 IJ— l!`C � l /
irraure, or a certificate of Worker's'Compensation Insurance,or HEATING-VENTILATING-AIR CONDITIONING r[(S
a cartifled copy thereof(Sec. 3800J-ab'.C.)
Policy No. Company
� ❑ Certified copy is heroCOUNTY OF LOS ANGE ES
by.turnished. � � BUILDING ANP SAFETY '
❑ Cartlflad copy is filed with the county building Inspection IN
BUILDING
Y
department. FOR APPLICANT TO FILL
Date Applicant (PRINT OR TYPE ONLY) ADDRESS
LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
COMPENSATION INSURANCE NEAREST }
Ald
Q.
(This section need not be tit feted it the work involved ABSORPTION UNIT, BTU CROSS ST_
8
by the permit is for one hundred dollan (3100) or lass.) DIMICT NO. VROC
I certlfy that In therformance of the work forwhich this AIR HANDLING UNIT CFM s',
p<ermIt Is issued, I shall not employ any person In any rahnner ✓' {J
so'as to beco a subject to the Workers' C mpensatlon Laws. BOILER BTU
APPROVALS DATE ECTOR AIR, IIB�J.I
Dit Appllcan COMPRESSOR BTU GL
ROUGH WW
NOTICE TO APPLICANT: If, after making t Certificate of VENTILATION SYSTEM Z
Exemption, you should become aubject to the Workers' FINAL
Compensatlon provisions of the Labor Code, you must forth-
Nvith comply with such provtalons or this permit shall be EVAPORATIVE COOLER VALID TION
deemed revoked.
LICENSED CONTRACTORS DECLARATION FURNACE: FAU o
FLOOR: BTU
I hereby•affl m that I am licensed under provialods of Chapter HEATER: SUSPENDED UNIT
9 (6omm6ncing with Section 7000) of Division 3 of the Busl- WALL
ness and Aofeasions Code, and my license la In full force and
effect. /f�^��
License NuMber4JQdC�11_ Lic.Clas(aV
Contract Date
❑ I am exempt from the licensing requirements as I am ■
licensed architect or a raglatered professional engineer Plan Check fee-25%Of above,
acting In my professional capacity (Section 7051, Bus-
iness and Professions Code). • ' 3.Q50
Uc.or-Reg.No. Data TOTAL FEE e,a 3 Q 5 06
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT 219-6 8 6'
I hereby, affirm that I am exempt from- the Contractor's NAME
License Law for the following reason (Section 7031.3, Busi-
ness and Professions Code): ADDRESS
❑ 1, as owner of the property, will do the,work and the
structure is- not intended or offered for sale (Section CITY TEL. NO.
7044, Business and Professions Code).
❑ OWNER
I, as owner of the property, am exclusively contracting AMA
with Ilcensed contractors to construct the project MAIL
(Section 7044, Busin'aas and Profeaalor+s Code). ADDRE
CONSTRUCTION LENDING AGENCY C11 TEL. NO.
I hereby affirrp that there is a construction lending agency -
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fol the performance of the work for which this permit is CONTRAC OR
44
issuedSec.3097,Civ.C.).
Lender.s Name_ ADDRE85
Lender's Address CITY TEL. N
I certify that I have readthis application and state that the. STALIC.
above information Is correct. I agree tb comply with all County E N CL
ordinances and State laws regulating Heating, Ventilating and
Air Conditioning, and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
County to enter upon the above-mentioned property for
levactLo'npur ses.
Signature of Perm tae DA.