HomeMy Public PortalAbout9256 WEDGEWOOD ST_Mechanical__ + W(IR*US'COMPENSATION DECLARATION CEA g 8C(2-80) APPLICATION FOR PERMIT
I WAf);;-,fflrm that I have a certificate of consent to self
insure, or a certificate of(Workers'Compensation Insurance,or HEATING-VENTILATING-AIR CONDITIONING
a certified copy thereof(Sec. 3800, Lab.C.) LJ
Policy No. Company
Certified copy is hereby furnished.
COUNTY OF LOS ANGELES BUILDING AND SAFETY
0 Certified copy is filed with the county building inspection I
department. FOR APPLICANT TO FILL IN BUILDING yIS
Date Applicant �1 d /
(PRINT OR TYPE ONLY) ADDRESS J �. !'Z
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 '�-5-1t� a
by the permit is for one hundred dollars ($100) or less.) DISTRICT NO PROCESSED BY O
t certify that in the performance of the work for which this _ AIR HANDLING UNIT,CFM O� 4DATEINSP70R'S
U
permit is issued, I shall not employ any person in any manner C71SIM
so as to become subject to the Work s' ompensation Laws. BOILER, BTU O
APPROVALS SIGNATURE VDate�PPlicant COMPRESSOR, BTU ROUGH -NOTICE TOA PLICANT: If, after m ing this Certificate ofVENTILATION SYSTEM
Exemption, you should become`s ject to the Workers' FINALC ZCompensation provisions of the Labor Code, you must forth- EVAPORATIVE COOL Rwith comply with such provisions or this permit shall be
deemed revoked.
LICENSED CONTRACTORS DECLARATION FURNACE: FAU V T n
FLOOR, TU (f
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.
License Number Lic.Class
Contractor Date
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 $
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
License Law fbr the following reason (Section 7031.5, Busi-
ness and Professions Code): ADDRESS
1, as owner of the property, will do the work and the CITY TEL. NO.
structure is not intended or offered for sale (Section
7044, Business and Professions Code). ---.d
OWNER
❑
I, as owner of the property, am exclusively contracting ' L
with licensed contractors to construct the project MAIL
(Section 7044, Business and Professions Code). ADDRESS
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit CONTRACTOR �'�r,�' +✓, Ci=r'
issued (Sec. 3 Civ.C.). �
Lender's Namee ADDRESS
Lender's Address
CITY ` y TEL. NO.
I certify that I have read this application and state that the STATE LIC.
above information is correct.I agree to comply with all County I LICENSE NO. CLASS
ordinances and State laws regulating Heating, Ventilating and
Air Conditioning, and hereby authorize representatives of this SEF;REVERSE FOR EXPLANATORY LANGUAGE
County to e r upon t e above-mentioned property for
inspectio ores.
jna"ermittee�1' Oate