HomeMy Public PortalAbout9843 WENDON ST_Mechanical__ 4VORKERS'COMPENSATION DECLARATION CEA g g(2-80) L���b�i� ®U ®� PERWT
I hereby affirm that I have if certificate of consent to self
insure, or a t'ertificate of Workers'Compensation Insurance,or HEATING-VENTILATING-AIR CON®ITOONING
a certified copy thereof(Sec.3800,Lab.C.)
Policy Company COUNTY OF LOS ANGELEt BUILDING AND SAFETY
❑ Certified copy is hereby furnished.
❑ Certified copy is filed with the county building Inspection FOR APPLICANT TO FILL IN BUILDING //�`►
department. ADDRESS
Date Applicant (PRINT OR TYPE ONLY)
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. O
by the permit is for ,one hundred dollars ($100) or less.) DISTRICT NO. PRO SED U
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM
permit is issued, I shall not employ any person in any manner Q/
so as to become subject to the Workers'Compensation Laws. BOILER,BTU
APPROVALS DATE INSPECTOR'S SIGN RE
LU
Date Applicant COMPRESSOR,BTU ROUGH N
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION.SYSTEMFINAL Ig•8,�-- Q �`,. 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: S D dJ�VI�T
9 (commencing with Section 7000)of Division 3 of the Busi=. A
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).
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 for the following reason (Section 7031.5; Busi-
ness d Professions Code): ADDRESS � �),
1, as owner of the property, will do the work and the �, 4 2 2 8
TEL.NOl�4-f S`G'J
structure is not intended or offered for sale (Section CITY , �� ��c,? �'�' *. o 0"0 o 4.1
7044,Business and Professions Code).
OWNER
❑ 2 0 0 1 7,00
I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project MAIL`
(Section 7044,Business and Professions Code). ADDRESS -75J o 0 1 '] `&4
CONSTRUCTION LENDING AGENCY CITY TEL.NO.
1 hereby affirm that there is a construction lending agency 0226-81
for the performance of the work for which this permit is CONTRACTOR C�AJ,5-
issued SSec.3097,Civ.C.).
Lender s Name ADDRESS
Lender's Address CITY TEL.NO.
I certify that I'have read,this application and state that theSTATE LIC.
above information is correct.I agree to comply with all County LICENSE NO. GLASS
ordinances and State laws regulating Heating,Ventilating:and
Air Condition ing,.and hereby'authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
County to enter upon the ;b�o.rnendoned property for
in on purposes.
Signature ..•Permittee Date _ _