HomeMy Public PortalAbout5565 RYLAND AVE_Mechanical__ WORKERS'9OMP.EV.SATION DECLARATION �. CE 8 8C(2 B � APP LLQ B C A T Q ON FOR P E R WT
I berebV-VMr n,4At ;-have a'•certificate of consent to Self ` an/ -
insure,or av4ertificFte,of Wdrkers'Compensation insurance,o.r + /'10 N p••IIEAVIfI G-VENTILATING-AI'R CONDIVBO61 ONG
aAe ted t�er�fe .3800,Lab.C.
Policy.N00'wJ OO 6 Qo1pany �� fW 7 `
Q Certified copy is heretiy furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is.filedwith the county building inspection BUILDINGde art ".nt FOR APPLICANT TO FILL,IN
Date �' X—MApplicantSP !r/ �� (PRINT OR TYPE-ONLY) ADDRESS'
LOCALITY Tel
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APBLIANCEL'OR EQUIPMENT FEE
•COMPENSATION INSURANCE NEAREST' },
(This section need not be completed .if the work involved ABSORPTION UNIT,BTU. CROSS ST: C
by, .the permit'is for one hundred.dollars (51.00) or less.) DISTRICT NO. ,V PROCESS BY 0
I,certify that in the performance.of thb,work'.for which this AIR HANDLING UNIT,CFM �jA �
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 INSP OR•S SIGNATURE W
Date Applicant COMPRESSOR,BTU. ROUGH i N
.NOTICE X.0 APPLICANT'-.If,.after making this Certificate of. VENTILATION SYSTEM FINAL Z
Exemption, :you should become.'subject 6 the Workers'
Compensation provisions,of the Labor Code'.110
. u must forth- EVAPORATIVE COOLER -
with ,comply withsuch provisions or this permit shall be VALIDATI N
deemed revoked. FURNACE: FAU G AVITY
LICENSED CONTRACTORS DECLARATION FLOOR: BTU •v
I hereby affirm:that-lam'licensed under provisions of Chapter 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: r
License.Number v 173a Lia Class�I OC/3 92
Contractor. G'!�N/a/D/� Dated
0 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-` '
iness and Professions Code)'. PERMIT ISSUING FEE$
;4.826A'
Lic.of Reg.No. Date TOTAL FEE
HOME OWNER-BUILDER DECLARATION # o.lo;o•o•0 8
PLAN CHECK APPLICANT
I -hereby. affirm that I am.'exempt,from,the Contractor's 'NAME °, P.2Q Jr Q
License,3 aw for the following reason (Section 70313, Busi-
ness and Professions Code): ADDRESS
OI as owner of the.property, will do the work and the () 6l 6 86
structure is not intended or offered'for sale (Section., CITY TEL.NO.
7044, Business and-Professions Code):
OWNER Ad
I, as owner of the-property,'am exclusively contracting -
with licensed contractors to,construct 'the project MAIL &.4
�
(Section 7044,Business and Professions Code). ADDRESS //.4.2
CONSTRUCTION LENDING.AGENCY CITY elf TEL.NO. Pla 4/Y
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is CONTRACTOR •2
issued[,Sec..3097,Civ.C.).
Lenders Name ADDRESS
Lender's Address CITY ` TEL.NO. f.a C
reAg
I certify that I have read this application•and state that the STATE
above information is correct.I agree to comply with all CountyLICENSE NO. ``YY S / CLASS
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
ins �
tion urpos�
�� �
Signature of Permitteee_/,1•/(�/✓/- Dat