HomeMy Public PortalAbout10906 WILDFLOWER RD_Mechanical__ WORKERS'COMPENSATION DECLARATION CEP'818Cf2-Bo) APPLICATION ' I'OR PERMIT '
I hereby affirm that I have'a' certificate. of consent to self
insure,or a certificate of Compensation;nsurance,.oi HEATING-VENTILATING-AIR CONDITIONING
a certified copy thereof(Sec.380.0,'Lab.C.) V
• Policy No. 442586•Company' Stat@ PIIM91
0' 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
Datedey t entgaAppltcaht ! cmd. Air, rna• (PRINT OR TYPE ONLY) ADDRESS
•LL �j NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY O
CERTIFICATE OF EXEMPTION FROM'WORKERS' V
COMPENSATION INSURANCE NEAREST
l�(This section need.not be completed if. the work involved :.ABSORPTION,UNIT,..BTU CROSS-ST. -
by the permit .is fdr one hundred dollars ($100) or less.) DISTRICT NO: ;'PROCESSED Y J`
I certify that in the performance of the work for which this' AIR HANDLING UNIT,CFM' LL
permit is issued,'I shall not employ any person in any manner >
so as to become subject to the Work'ers'.Compensation Laws. BOILER, BTU.
APPROVALS DATE INSPECTOR'S SIGNATURE QIP
Date Applicant COMPRESSOR,BTU" ROUGH 0
NOTICE TO APPLICANT: If, after tusking this Certificate of �1ENTILATION SYSTEM
.Exemption, ydu should become, subject to the Workers' FINAL W
Compensation provisions of the.Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION
with comply with such- provisions or this permit shall be
deemed revoked. r lCC/
LICENSED CONTRACTORS DECLARATION FURNACE: FAU. VITY t✓ �F� f
FLOOR: BTU f
I hereby affirm that I am licensed under provisions of Chapter• HEATER: SUSPENDED UNIT
9 .(commencing with.Section 7000)-of.Division 3 of the Busi- WALL
ness'and Professions Code, and my license is in full force and
effect. 7., f/',v''✓`a
Licenie'Number 33�a8 ,•LLic.Class' C20
Contractor AM 'TOW' •AUa 121/6/82
I am exempt from•the licensing requirements as f am a '
.licensed architect or.a registered profe;;siorial engineer Plan check-fee 25%of above.
acting in my•.professional capacity (Section 7051, Bus-
iness and Professions Code). PERMIT ISSUING FEE$
Ltc.or Reg..Nb. Date TOTAL FEE
HOME.OWNER-BUILDER DECLAR•ATIO14 'PLAN CHECK APPLICANT
'I hereby•affirm that I'am•exempt from the Contractor's NAME
License Law for the following-reason (Section.703.1..5, Busi-
ness and Professions Code):' ADDRESS
O I, as owner of the property, will do the work.'and'the.
CITY TfiL. NO. ;h xi"I"
structure is not intended or offered for sale (Section - a• tll!6:
7044,Business and Professions Code).' I •,
OWNER �lBXt°�tf s
I, as owner,.of the property, am.exclusively contracting- r�
with licensed contractors to 'construct the project MAIL 15
��Im'a;' ^J
(Section 7044,Business and Professions.Code)., ADDRESS 10906 Wildflower' 'toad �+ I.
CITY TEL.NO.
CONSTRUCTION LENDING AGENCY 2'�;�B City d44•�i 99 I .
I hereby,affirm .that there is a construistton lending agency o-•1 ; '
for the performance of the work for,which this permit is CONTRACTOR An jr4k ndjtjoned Ajr, Zoo.
issued SSec::3097,Civ.C).
Lerider s Name ADDRESS
Lender's Address CITY 81 TEL.NO. 579"3800
I .certify that I have read this application and state that the STATE 293529 LIC. C20 '
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 h,er by authoritie representatives of this SEE REVERSE" FOR EXPLANATORY LANGUAGE 7
County to enter :4paliy to abpve-mentioned property for y
inspection purposes:'. v /
DAiTId L'r088.l. .:e '"' 121.16182
Signature of Permittee Date