HomeMy Public PortalAbout10928 WILDFLOWER RD_Mechanical__ WORK°ERS COMPENSATION D:EGLAR.ATION CE 818(2-80) PLIC ®U FOR P E R M OT
•..I hereby affirm that I,'have a• certificate of consentto self
insure.,or a certificate of Workers'Compensation Insurance,o'i
a certified copy thereof(Sec,3800,Lab.C.) /�I
HEATING-VEI�VILATING-Alla CONDITIONING
Policy No. Company ��
or
� � i COUNTY OF LOS ANGELES. BUILDING AND SAFETY
❑ Certified copy is'hereby furnished, ";• 1'
entified copy is filed with the county building inspection BIJI LDING
depa en . FOR�APPLICANT'TO FILL IN AbDRESS '
bate Applicant + (PRINT OR TYPE ONLY)
i' LOCALITY',
CERTIFI.CATE OF EXEMPTION FROM WORKERS' NO: TYPE OF APPLIANCE OR EQUIPMENT FEE
COMPENSATION INSURANCE 1 NEAREST }
(This Section., need.not be completed if•the work. involved 6 ABSORPTION UNIT,BTU.
GOOSS'ST. o'
by the permit is for. one hundred"dollars ($1.00) or. less.) DISTRICT NO: PROCESSED v• V
AI`R HANDLING UNIT,CFM (
I certify that in the performance of the.work for which this ,� • I �� � �• 1]C
permit is issued, I shall not employ any person in any manner r j O
so as to become subject to the Workers'Compensation Laws. ^ BOILER, BTU IH
t APPROVALS, DATE INSPECTOR'S SIGNATURE .C.)
Date Applicant t COMPRESSOR,BTU.1,04dAgR!6
UGH
APPLICANT: If, after making this Gerfificate of } VE.NTILATI.ON.SY'STEfVf Z
R,O
UGH
Exemption, you. should `become,subject to the Workers' I' FIN.AL
Compensation provisions, of-the Labor Code,you must forth- I;
with comply with 'such provisions or this permit shall. be EVAPORATIVE COOLER 4 VALIDATION
deemed revoked. �, FURNACE: FAU GFj /ITY
n
LICENSED CONTRACTORS DECLARATION kki. FLOOR: BTU--
I
TU I hereby affirm that I am licensed under provisions oiChapter HEATER:.. SUSPENDED' ,UNIT_. d
9 (commencing with.Section 7000)of Division 3 ofthe Busi- WALL.
111
ness and Professions Code; and"my License is in'full force ai►d.
effect.'
_ •: .. _ .. ...... _ _ .... . . ... _ , ... :
C W s
License NumberMWS Lie.Class
ContractorAna — Date D g '
❑4.I am exempt from the licensing req rem 'ts as''I,am a
licensed arpNifect. or a registered:professional dngineer ;i Plan check fee 2;5010 of above.., • , ),'
acting in my professiorial:,capacity- (Section '7051, Bus- d
iness and Professions Code.), �, PERMIT ISSUING FEE$ ,.
Lic,or Reg.-No. Date TOTAL FEE
aa
-:HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT.
I hereby'�affirm that'I am•'exempt. from-the Contractor's ' —NAME'
License Law for the. following ieason (Section 7031.5; Busi= {
ness and Professions Code): ADDRESS 1
❑ I, as owner of the property, will do the work and the
structure Is not intended or offered for sale (Section ' CITY TEL.NO; -,
7044,Business and Professions Code). 2 0 2 27,A-iM ,
OI, as owner of the"property, am exclusively contracting N E R _ ll L' E R ,
with licensed contractors to congtruct the project AIL I ' ��jj \'I' `,' #
Section 7044,Business and Professions Code ADDRESS O 2,O Vv I`�� L•O Vv�••
CONSTRUCTION'LENDING"AGENCY tt CITY TEL.NO. r
I hereby affirm that there is a construction lending agency S , !' o. _
for the performance of the work-for which this permit is CONTRACTOR �8 �� •�"- '.'.00 c5,
issued(Sec.3097'Civ.C.). ) ZO4,:Lender'sName ADDRESS8Lender's Address CITY TE.L.NOI 'certify that I have read this application and state that the ,I STATE LIC.above information is correct.I agree to comply with all County LICENSE NO. CLASSordinances•and State laws regulating Heating,Ventilating and Air Conditioning,and" reby authorize represent byes of this' 'i SEE REVERSE FOR•EXPLANATORY LANCrUAGE Count o enter o :above-mint' nod roperty for '
s t' nooses.
ignat a of Permitteg