HomeMy Public PortalAbout9849 VAL ST_Mechanical__ '1�C ' lis'COMPENSATION DECLARATION CEA 818C(2-80) L�-r�Cd� �O �l FOR PE R UVp QT
I 'pfly�iwn that I have a' certificate of consent to self
.C;r i e a certificate of Workers'Compensation Insurance,or HEATING-VENTILATING-AIR CONDITIONING
a certific co thereof'pSec.,}800,Lab..&:.)
Policy No. G6mpajJny ' COUNTY OF LOS ANGELES 64JILOIEiIG
❑ Certfffed copy fs hereby furnished. AND SAFETY
❑ Certified co is filed with the count r uildin
copy ginspection FOR APPLICANT TO FILL IN BUILDING
d art nt
Date X . Applicant (PRINT OR TYPE ONLY) ADDRESS
LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
COMPENSATION INSURANCE NEAREST
(This section need not be completed if the work involved ' ABSORPTION UNIT, BTU CROSS ST. ' ��• a
by the permit is for one hundred dollars ($100) Or less.) DISTRICT NO. J PROCESSED BY V
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM h
permit is issued, I shall not employ any person in any manner Ir
so as to become subject to the Workers' Compensation Laws. BOILER,BTU
� 4 APPROVALS DATE INSP TOR'S SIG ATURE U
Date Applicant COMPRESSOR,BTU ROUGH W
CL
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers' e
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER
with comply with such provisions or this permit shall be 1 VALIDATION
deemed revoked. FURNACE: FAU GRAVITY—
LICENSED
R ITY LICENSED CONTRACTORS DECLARATION FLOOR: BTU
I hereby affirm that I am licensed under provisions of Chapter HEATER: SUSPENDED UNIT
9 (commencing with Section 7000)of Division 3 of the Busi- WALL .
ness and Professions Code, and my license is in full force and
effect. .00
/ llo
License Nupemberh �L+'L Lic.Cluss � 0
ContractoLlL�• 116 S&INIZ 1IbftDate- �J
❑ lam exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer Plan check fee 25%of above.
acting in my professional capacity (Section 7051, Bus-
iness and Professions Cade). PERMIT ISSUING FEE$ O
t
Licaor Reg.No. Date TOTAL FEE Q
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that 1 am exempt from- the Contractor's NAME
Liccr,Xe Law for the following reason (Section 7031.5, Busi-
ness ind Professions Code): ADDRESS /�/�/+
❑ I, as owner of the property, will do the work and the Min4T■4
structure is not intended or offered for sale (Section CITY TEL. NO. 7 ■Vtl
7044, Business and Professions Code). ITEMS
Vl
❑ OWNER 1 ITEPIS
I, as owner of the property, am exclusively contracting .7
with licensed contractors to construct the project MAIL /fitL
(Section 7044,Business and Professions Code). ADDRESS TOTAL 48.00
CITY TEL.NO. CHECK 48■00
CONSTRUCTION LENDING AGENCY � � II++t��.11gqt�,���T
I hereby affirm that there is a construction lending agency CONTRACTOR 4r7rllti �I
for the performance of the work for which this permit is ■
issued(Sec.3097,Civ.C.).
Lender's Name ADDRESS
Lender's Address CITY TEL.NO. 1301 7/27/89
I certify that I have read this application and state that the STATE LIC. 4708 1 AM10e52
above information is correct.1 agree to comply with all County 11 LICENSE NO. CLASS
ordinances and State laws regulating Heating, Ventilating and
Air Conditioning, and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE j
County to enter upon the above-mentioned properly for
inspecti r ses.
6 � . �—
Si nature of Permittee ate