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HomeMy Public PortalAbout10902 WILDFLOWER RD_Mechanical__ Wl7RKERS'.COMPENSATION DECLARATION CEA3818(2-80) A P PU C A T�®ISI FOR P E R T I he'_*by affirm that I have a' certificate of consent to self iri8ure,ora certificate of Workers'Compensation Insurance,of FIE.ATING-VENT ILATING-AI•I2 CONDITIONING a certified copy thereof(Sec.3800,Lab.C.) Policy No. Company F1 Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY ❑ Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN BUILDING �,{► department. ADDRESS �© ®C dW� Date Applicant (PRINT OR TYPE ONLY) CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF.APPLIANCE OR EQUIPMENT FEE LOCALITY COMPENSATION INSURANCE NEAREST IV } (This section need not be completed if the work involved ABSORPTION UNIT, BTU CROSS ST. tl by the permit is for 'one hundred dollars ($100) or less.) DISTRICT NO. PROCESS D v V I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM permit is issued, I shall not employ any rson in any manner V(� O so as to become subject to the W rkers' o ation Laws. BOILER, BTU rp,�r n J� APPROVALS DATE INSPfiCTO SIGNATURE W Date- ant COMPRESSOR,BTU v UU ROUGH . z NOT1C TO API LICANT: If, after making this Certif ate of VENTILATION SYSTEM r _ Exemption, you should become subject to the Workers' FINAL Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION with comply with such provisions or this permit shall be . ' deemed revoketl FURNACE: FAU TY D/1 �,l L / LICENSED CONTRACTORS DECLARATION �. FLOOR: U V !!�� i7 I hereby affirm that.1 am licensed under provisions of Chapter HEATER: SUSPENDED NIT 9 (commencing with Section 7000)of Division 3'of the Busi- WALL ness and Professions Code., and my license is in full force and 4 !1 effect. (J 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 705.1', Bus- iness and Professions Code). Lic.or Rek.No. Date TOTAL FEE HOME OWNER.BUILDER DECLARATION PLAN CHECK APPLICANT I hereby affirm that I am exempt from-the Contractor's NAME `F License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): ADDRESS 4 7'1.2'A ❑ 1, as owner of the property, will do the work and the / structure is not intended or offered for sale (Section CITY TEL.NO. y— � [ # 0 0 0 0 0 $' 7044,Business and Professions Code). , 10 Aa I OWNER I, I e o 4 Q 5 0 I, as owner of the property, am exclusively contracting with licensed contractors to construct the projectMAIL25 (Section 7044,Business and Professions Code). ADDRESS © o 0:0 4 0.5 0 CONSTRUCTION LENDING AGENCY CITY TEL.NO 0 5 2 7 a H 6 I hereby affirm that there is a construction lending agency CONTRACTOR for the. performance of the work for which this permit is issuedSSec.3097,Civ.C.). Lenders Name ADDRESS, a Lender's Address CITY TEL.NOS71- I certify that 1.have rend this application and state that the STATE LIC. above information is correct.I agree to comply with.all County LICENSE NO. CLASS ordinances and State laws regulating Heating, Ventilating and Air Conditioning, and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE County to a ter p n the above-mentioned properly for i� on p ose �F L CJ q!Iti3atura.of.Peimittee Date _ ,