HomeMy Public PortalAbout4903 RYLAND AVE_Mechanical__ J WORKERS'COMPENSATION DECLARATION 7GA 8 s (2-so) A D P L IC AT I O �O R P E IT
1 hereby affirm that I kave a cVtificate of consent to self CE-
insure,of a certificate of Workers'Compensation Insurance,or HEATING-VENTILATING-ABR CONDITIONING
a certified copy thereof(Sec.3800,Lab.C.)
Policy No. Company.
Certified copy is hereby furnished. COUNTY OF LOS ANGELES �/�' BUILDING AND SAFETY
Certified copy is filed with the county building inspection BUILDING C.)`, �` /V)3department. FOR APPLICANT TO FILL IN V r
Date Applicant (PRINT OR TYPE ONLY) ADDRESS
. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY
NO
CERTIFICATE OF EXEMPTION FROM WORKERS' - —`=
COMPENSATION INSURANCE NEAREST }
(This section need not be completed if the work involved ABSORPTION UNIT,BTU a CROSS ST. O L j 't 7 Z U Z. �-
O
by the permit is for one hundred dollars ($100) or less.) DISTRICT NO. PR ss BY V
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM cc
permit is issued, I shall not employ any person in any manner O
so as to become subject to the Workers'Compensation Laws. BOILER,BTU
APPROVALS DATE INS PECTOR• GNATURE LJ.1
Date Applicant COMPRESSOR,BTU ROUGHy
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL ���� 4�'- � Z
Exemption, you should become subject to the Workers'
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 FLOOR: BTU
I hereby affirm that I am licensed under provisions of Chapter HEATER: SUSPENDED UNIT
9 (commencing with Section 7000)of Division 3 of the Busi-
ness and Professions Code, and my license is in full force and
effect.
License Number Lic.Class
Contractor Date
ElI 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-
iness and Professions Code). PERMIT ISSUING FEE $ V
Lic.or Reg.No. Date TOTAL FEE —
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from-the Contractor's NAME J i PJ-ol
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): ADDRESSi
I, as owner of the property, will do the work and the TEL. NO.Lf
%tructure is not intended or offered for sale (Section
7044, Business and Professions Code). O 8 7
I, as owner of the property, am exclusively contracting OWNER J e I rrt•
with licensed contractors to construct the project [MAIL # 0 0 0 0 0 8
(Section 7044,Business and Professions Code). R SS
CONSTRUCTION LENDING AGENCY CITY TEL.NO. 2 ° ° 7.00
I hereby affirm that there is a construction lending agency 'o o 0
for the performance of the work for which this permit is CONTRACTOR 7,0 1.
issued(Sec.3097,Civ.C.).
Lender's Name LADDRESS 0 8. 1 9-81
Lender's Address TY TEL.NO.
I certify that I have read this application and state that the ATE LIC.
above information is correct.I agree to comply with all County CENSE NO. CLASS
ordinances and State laws regulating Heating, Ventilating and
Air Conditioning, and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
LI' p
ty to enter upon the above-mentione proper y for
cion purposesre o ermtttee' Dat