HomeMy Public PortalAbout5552 RYLAND AVE_Mechanical__ I76A364C
WC}R'LERS'COMPENSATION DECLARATION CE-818(2.80) APPLICATION FOR PERMIT
I hereby affirm that I have if certificate of consent to self
insure,8r a certificate of Workers'Compensation Insurance,or i HEATING-VENTILATING-AIR CONDITIONING
a cerfified copy thereof(Sec.3800,Lab.C.)
Policy No.—, Company
❑ Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING ARID SAFETY
❑ Certified copy is filed with the county huilding,inspection FOR APPLICANT TO FILL IN BUILDING ss��
Department. R11114#4; p�
Date Applicant (PRINT OR TYPE ONLY) ADDRESS
CERTIFICATE OF EXEMPTION FROM WORKERS'
NO. I TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY m Ile JZ 9)� G
COMPENSATION INSURANCL NEAREST D }
(This Section need not be completed if the work involved ABSORPTION UNIT, BTU CROSS ST. Q e ��
O
by the permit is for one hundred dollars ($100) or less.) DISTRICT NO. EDBY U
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM i 9c:05Lill- O
permit is issued. 1 shall not employ any person in any manner
so as to become subject to the Workers' om ens on Laws. BOILER, BTU F'
/¢ � �c APPROVALS DATE INSPECTOR'S SIGNATURE W
--Date Applicant_��� � l 4— COMPRESSOR,BTU "" uO ROUGH N
NOTICE TO APPLICANT: if, after m ' ng this Certificate of VENTILATION SYSTEM Z
Exemption, you should become su ect to the Workers' FINAL —
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOL! A DATI
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: F A Ul-' GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that 1 am licensed under provisions of Chapter r HEATER: SUSPENDED UNIT
9 (commencing with Section 7000)of Division 3 of the Busi- WALL
ness and Professions Code, and my license is in full force and
effect.
Licence Number Lic.Class
Contractor Date
❑ I am exempt from the licensing requirements as 1 am a
licensed architect or a registered professional engineer Plan check fee 25%of above.
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code). PERMIT ISSUING FEE$
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
Licence Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): ADDRESS RCCT■T
❑ 1, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section CITY TEL. NO. 307 3,■TJ
7044,Business and Profcssions'Code). I ITEMS
OWNER
I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project MAIL TOTAL ,,_
4 00
(Section 7044, Business and Professions Code). ADDRESS
CONSTRUCTION LENDING AGENCY CITY TEL.NO. CHECK 34■00
I hereby affirm that there is a construction lending agencl CHAWK ■0�{
for the performance of the work for which this permit is CONTRACTOR
issued(Sec.3097,Civ.C.).
Lender's Name ADDRESS �fft�il 1 1
Lender's Address CITY TEL.NO. =-coal 8/ju/8Te
1 certify that I have read this application and state that the STATE LIC. 5155 1 AM 944
above information is correct.I agree to comply with all County ILICENSE NO. CLASS
ordinances and State laws regulating Hearing, Ventilating and
Air Conditioning,and hereby authorise representatives of this SEI, REVERSE FOR EXPLANATORY LANGUAGE.
County to enter upon he above. entioned property for
insp ion p pos
ignature o Permittee Date