HomeMy Public PortalAbout9750 VAL ST_Mechanical__ WORKERS COMPENSATION DLCLARATION 76A364C
I hercb} affirm that I hate a certificate of consent to ,elf CE SIB (z BD) APPLICATION FOR PERMIT
insure or a certificate of Workers Compensation Insurance or HEATING-VENTILATING-AIR CONDITIONING
a cert O �ipy thereo (Secy JBOr)..J ab C - /�/
Pohcv Com
Cutrfied copy is hereby furnished COUNTY OF LOS ANGELES BUILDING AND SAFETY
eCertified copy is filed wtl the county building inspection FOR APPLICANT TO FILL IN BUILDING Qy�� y�
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Date Applicant C � (PRINT OR TYPE ONLY) LOCALITY
O DUTY
LOCALITY '•
CLRTII ICATE OF GtMPTION FROM WORKERS NO TYPE OF APPLIANCE OR EQUIPMENT FEE
COkIPLNSATION INSURANCL NEAREST JJ T
(This $Belton need not be completed If the Rork Involved ABSORPTION UNIT BTU CROSS ST IL
by the perms[ is for one hundred dollars ($100) or less) DISTRICT NO PRocESSEO By 8
I certify that In the performance of the work for which this AIR HANDLING UNIT CFM X
permit Is Issued 1 shall not employ any person In any manner < v� O
so as to become subject to the WorkLrs Compensation Laws BOILER BTU SPU
APPROVALS DATE INSPECTOR$SIGNATURE
W
Date Applicant COMPRESSOR BTV
ROUGH 05
NOTICL TO APPLICANT If after making this Certificate ofVENTILATION SYSTEM FINAL 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 rexoked
FURNACE FAU_ GRAVITY
l KENSLD CONTRACTORS DECLARATION FLOOR BTU
—
I hereby affirm that I am licensed under provisions of Chapter HEATER SUSPENDED UNIT l
9 (commencing with SLetlon 7000)of Division 3 of the Bust
ties, and Professions Code and my IicensL IS In full force and
effect �J L
License Nb rsl�� Lie ClnsCs�� `�
Conlractor9r_/ ��Le.—gate
I am exempt from the Ir9Lnsmg requir,ments as 1 am a
ImLnsed architect or a registered professional engineer Plan check fee 25% of above
acting in my professionalcapacity (Section 7051 Bus PERMIT ISSUING FEE $ Q
mess and Professions Code) _
Lie or Reg No Dna TOTAL FEE 5�
HOME OWNER BUILDER DFCI ARATION PLAN CHECK APPLICANT
1 hercb} affirm that 1 am exempt from the Contractors NAME6 f t�il4t
License Law for the following reason (Section 7031 5 Bus, w_��
nest and Professions Code) ADDRESS
1 as .,net of the property will the work and rhe
structure Is not intended or offered for sale (Section CIT Oil U TEL NO
7044 Business and Professions Code) - —�
❑ OWNER
1 as owner of the property am exclusively contracting R 5 0 Q.8 A
with licensed contractors to construct the project MAIL
(Section 7044 Busmeas and Professions Cod L) ADDRESS'9]Sv x/ 11P 8
CONSTRUCTION LENDING AGENCY CIT TEL-/-y/�/w�'TEL NO 29205 0
I hueb} affirm that there is a k for
lend mg agency C�%9 �t.rA/J '
For the performance of the work for which tau permit a CONTRA ins• . 20505
Issued (See 3097 Civ C )
Lenders Name A D D R E d 0`908-83
Lender s Address CIT Y�VV' Q/ TEL N �b-3/p i
I evUfy that 1 have read this application and state that the STATEe3// OG/ LIC
above Information ,s correct I agree to comply with all Count} LICENSE NO /'�J CLASS
ordinances and State laws regulating Heating Ventilating and
Air Conditioning and hueb} authonrt represcnlatlses of this Sl P REVERSE I OR LXPLANATORN LANGUAGE
Count} to Litter upon the Ibose mentionLd property for
IS i Ion pnr yes If -7—
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