HomeMy Public PortalAbout9819 WENDON ST_Mechanical__ WORKERS'COMPENSATION DECLARATION .CEA3664C 18 BO) fa I�I�p ��` q ®gyp fC®� I�I�11 L1 ��r
I hereby affirm that I have s' certificate of consent to self - A If— lr I� ` A p t7 Ir E If'(IIS 0 II
insure, or a certificate of Workers'Compensation Insurance,or p-EATING-VE:NTIL,ATING-�R COW®GYIOh�I11�IC9
��erti;wd co t o ec.3800, C.)
flPcy1�m r,i J T!��OP n —
Certified copy is hereby urnished.
COUNTY OF LOS ANGELES BUILDING ARID SAFETY
Certified copy is filed with the county building inspection BUILDING
p t ��/
FOR APPLICANT TO FILL IN �`.
Dat Applicant Jv L`-ti�� (PRINT OR TYPE ONLY) ADDRESS
LOCALI
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. 9� a
by the permit is for one hundred dollars ($100) or less.) DISTRICT NO. PROCESS 9Y _ V
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM *-- a
permit is issued, I shall not employ any person in any manner ti� l.� , 0 t7 O
so as to become subject to the Workers'Compensation LaWs. BOILER,BTU V
APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant COMPRESSOR,BTU ROUGH - N
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEMFINAL' S 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 revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION ' FLOOR: BTU ,
I hereby affirm that I am licensed under provisions of Chapter HEATER: SUSPENDED UNIT
9 (commencing with,Section 700.0)of Division 3 of the Busi- WALL
ness and Professions Code,and my license is in full force and d
effect. �.
License Nurn A Lic.Class r' -
Contrac 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 profession;capacity (Section 7051, Bus-
iness and Professions Code).
Lic,or Reg.No. Date TOTAL FEE 33 sIII
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT .
I hereby affirm that 1 am exempt from- the Contractor's NAME ,
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code):, ADDRESS /d7 41
I, as owner of the property-, will do the work and the
Cli-�' ' / TEL:N
structure is not intended or offeSed for sale (Section J'/
7044, Business and Professions Code). FJ ;2'3.-3A 4 A
❑ OWNER a ���- /(J ,
I, as owner of the property, am exclusively contracting �'o�o'o'o o $•
with licensed contractors to construct the project MAIL �' `,��
(Section 7044,Business and Professions Code). ADDRESS h"/
2,°k° 3350 .
CONSTRUCTION LENDING AGENCY CITY TEL...
I hereby affirm that there is a construction lending agency 335020:
for the performance of the work for which this permit is CONTRACTOR -
issued(Sec.3097,Civ.C.). 3 8—8 2
Lender's Name ADDRESS
Lender's Address 2.AE
f TEL.N s
�.
or
1 certify that I hav this application and state that the
above i ormation' corr t.I agree to comply with all County° O. Y :CLASS
ordinalhices to a Is regulating Heating, Ventilating and
Air Co ion g, her by authorize representatives of t is , SEE REVERSE FOR EXPLANATORY LANGUAGE
t• to a po he above-mentioned pr arty for'
in t;c o S, le. - ..
Signatur o to If