HomeMy Public PortalAbout9860 WENDON ST_Mechanical__ WORKERS•,COMPENSATION DECLARATIONCEA gs g(Z.gO) APPLICATION FOR PERMIT
I hereby affirm" 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.)
Policy No. Company
❑ Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
❑ Certified copy is filed with the county building inspection BUILDING
department. FOR APPLICANT TO FILL IN
Date Applicant (PRINT OR TYPE ONLY) ADDRESS
LOCALITY �
I0. TYPE OF APPLIANCE OR EQUIPMENT FEE
CI RTIPICATE OF EXEMPTION FROM WORKERS' O
COMPENSATION INSURANCE NEAREST U
(This section need not be completed if the work involved ABSORPTION UNIT, BTU CROSS ST. ; LU
by the permit is for one hundred dollars ($100) or less.) DISTRICT NO. PROCESSED BY —I
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM t LL
permit is issued, I shall not employ any person in any manner >_
so as to become subject to the Workers' Compensation Laws. BOILER, BTU Ir
APPROVALS DATE INSPECTOR'S SIGNATURE Q
{
Date'' Applicant (r� COMPRESSOR, BTU ErROUGH O
N IC:E TO APPLICANT: If, after making this Certificate of — — a
VENTILATION SYSTEM FINAL o-
E ption, you should become subject to the Workers'
C"` pensation provisions of the Labor Code, you must forth-
comply with such provisions or this permit shall be
EVAPORATIVE COOLER 1
d` ed revoked.
FURNACE: FAU GRAVITY
LICENSE:D CONTRACTORS DECLARATION FLOOR BTU t
I: reby affirm that I am licensed under provisions•of ChapterHEATER: SUSPENDED UNIT
a' onimencing with Section 7000) of Division 3 of the Busi- WALL
n and Professions Code, and my license is in full force and
el ct.
L nse Number Lic.Class
Cf itractor 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 $
< ,r Reg.No._ _Date TOTAL FEE
HOMIi OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
1 iereoy affirm that 1 am exempt from- the Contractor's NAME
Li ense Law for the following reason (Section 7031.5, Busi- -
ne,s,and Professions Code): ADDRtSS %
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).
❑ --
I, as owner of the property, am exclusively contracting OWNER
with licensed contractors to construct the project MAIL
(Section ;044, Business and Professions Code). ADDRESS
CONSTRUCTION LENDING AGENCY CITY TEL. NO.
I hereby affirm !hat there is a construction lending agency
for thi4performance of the work for which this permit is CONTRACTOR
issued Sec. 3097,Civ. C•).
Lenders Name_._._ ADDRESS
Lender's Address__
CITY TEL. NO.
I certify that I have read this application and state that thegTATE LIC.
above information is correct. 1 agree to comply with all County LICENSE NO. CLASS
ordinances and State laws regulating Heating, Ventilating and i
Air Conditioning, and hereby authorize representatives of this ) SEF. REVERSE FOR EXPLANATORY LANGUAGE;
County to enter upon the above-mentioned property for
inspection purposes.
s
Signature of Permittee Date a
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