HomeMy Public PortalAbout9855 VAL ST_Mechanical__ WORKERS' COMPENSATION DECLARATION APPLICATION FOR PERMIT
I hereby w+Ffirm that I have a certificate of t:onsdnt to self
insure, or a certificate of Workers' Compensation InsJrance, 76A364C HEATING - VENTILATING - AIR CONDITIONING
ora certified copy thereof (Sec. 3800, Lob. C.) �r.- t
20-0046 DPW 9/88
Policy No. Company
❑o%Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
❑ Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BU DING
tion department. (PRINT OR TYPE ONLY) ADDRESS
V
Date Applicant LOCALITY j `L-
- /
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE L
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST.
(This section need not be completed if the work involved by
ABSORPTION UNIT, BTU DISTRICT NO. PRO SS BY
the permit is for one hundred dollars($100) or less.) AIR HANDLING UNIT, CFM
I certify that in the performance of the work for which this ,
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws. BOILER, BTU ' r APPROVALS DAT NS TORS SIGflA5JRE
DateApplicant COMPRESSOR, BTU rJI V ROUGH
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER V DA
with comply with such provisions or this permit shall be deem-
ed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT-
(commencing with Section 7000)of Division 3 of the Business WALL
and Professions Code,and my license is in ful I force and effect. /
I 1CPY� >_
CL
License Number Lic. Class , O
V
Contractor Date
❑ I am exempt under Sec.
Plan check fee M
B.&P.C. for this reason. CL
PERMIT ISSUING FEE $ Z
Date: _
TOTAL FEE
_
Signature
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License ! G� ,
Law for the followingreason Section 7031.5, Business and NAME _
Professions Code): r t
ADDRESS �g '
1, as owner of the property, or my employees with �! +`:t �_
wages as their sole compensation,wi l l do the work andc f l';
the structure is not intended or offered for sale(Section CITY �'' fZ TEL. NO. , � ;� _� ..:_
7044, Business and Professions Code). OWNER i4
❑ i
I, as owner of the property, am exclusively contracting
EM
with licensed contractors to construct the project (Sec- MAIL TOTAL 59 .00
tion 7044, Business and Professions Code). ADDRESS L cy+l,i�
CONSTRUCTION LENDING AGENCY CITY TEL. NO. '�ryK 7
r
I hereby affirm that there is a construction lending agency for , i:i.iMG-E .00
the
LI-
the performance of the work for which this permit is issued CONTRA OR
(Sec. 3097, Civ. C.).
ADDRESS 11,00�_I3001 31/ I
Lender's Name if V Y�'
AIS 10 -
'C �,�_
Lender's Address CITY TEL. NO. 94�'`!
I certifythat I have read this application and state that the STATE LIC.
pp LICENSE t 10. CLASS
above information is correct. I agree to comply with all County
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter
A
th a ve-ment' ned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
of Applicant or Age Dote @
76A364C *, �
CE-,4W(REV.11/78)
®s APPLICATION FOR PERMIT
HEATING - VENTILATING - AIR CONDITIONING
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN BUILDING (j r-
(PRINTORTYPEONLY) ADDRESS (� V
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY -f-em je Ivg
NEAREST
CROSS ST. j d hC/ W4'�v� ,(3L•I/ �
ABSORPTION UNIT,BTU
OWNER a olvAl kz.,,17 •Y M
AIR HANDLING UNIT,CFM MAIL
1
ADDRESS Sv Poll
BOILER,BTU / CITY i�7 TEL.NO.Al
/ COMPRESSOR,BTU b d d� ,a Cj CONTRACTOR
VENTILATION SYSTEM .
ADDRESS , .A,
EVAPORATIVE COOLER CITY A 9 �✓ J`/� TEL.NO.e4)/gds
FLOORL C ,
FURNACE: FAU BTU GRAVITY O STATELIC.
NO. /L} 666 LIC. fy q a
CLASS
HEATER: SUSPENDED UNIT_ APPROVALS DATE INSPECTOR'S SIGNATURE
WALL
ROUGH
FINAL �'�yy•� C-4--.0 0
INSPECTION RECORD CS
Vt-
Plan check fee 25%of above. m
PERMIT ISSUING FEE$
TOTAL FEE '7
PLAN CHECK A�P)PLICANT6 O C rD PLAN CHECK VALIDATION
NAME.
ADDRESS a � aR 4v�
` CITY dtummolv TEL.NO.l'q/.:7_.Jlr
�t a 1 1,Q•A
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND
STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY WITH ALL 0 0 0 O (1
ORDINANCES AND LAWS REGULATING HEATING, VENTILATING, AIR
CONDITIONING. PERMIT VALIDATION
I HEREBY CERTIFY THAT I AM NOT ACTING IN VIOLATION OF I 0 - 2700
CHAPTER 9, DIVISION 3, OF THE BUSINESS AND PROFUSICINAL CODE
OF THE STATE O CALIFOR IA. l/l// Z 0 0 0 `2%,(�Q U
SIGNATURE
OFPERMnTEE
0225-80
DISTRICT NO. PROCESSED BY
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