HomeMy Public PortalAbout9552-9554 WOODRUFF AVE_Mechanical__ WQRKERS'COMPENSATION DECLARATION CEA S B (2-80) A P P L IC AT I O Ill FOR PERMIT
4' hereby affirm that I have a• certificate of consent to self 1
insure,or a certificate of Workers'Compensation Insurance,or 1
a certiflec�Wopy�herr f,(S_�c.3800, 3 C.)
BEATING-VENTILATING-AIR CONDITIONING
PolicGy–N70. s/CCo(Jmpany � ��� ee
❑ Certified copy is hereby furnished. / —�/ I COUNTY OF LOS ANGELES i BUILDING AND SAFETY
ertified copy is filed with the cou y di ns on ' FOR APPLICANT TO FILL IN BUILDING
depart a t.�p�
ADDRESS s-s-z
Date Jz W – Applicant i (PRINT OR TYPE ONLY)
CERTIFICATE OF EXEMPTION FROM WORKERS' I NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY
COMPENSATION INSURANCE I NEAREST p }
(This section need not be completed if the work involved ABSORPTION UNIT,BTU CROSS ST, �f��a 7 O
by the permit is for one hundred dollars ($100) or less.) I DISTRICT NO. P s V
I certify that in the performance of the work for which this i AIR HANDLING UNIT,CFM ; �,} vf�
permit is issued, I shall not employ any person in any manner f L o
so as to become subject to the Workers'Compensation Laws. BOILER,BTU 1
APPROVALS DATE INSPECTOR'S S ATURE W
Date Applicant COMPRESSOR,BTU tL
ROUGH N
NOTICE TO APPLICANT: If, after making this Certificate of I VENTILATION SYSTEM Z
Exemption, you should become subject to the Workers' FINAL —
Compensation provisions of the Labor Code, you must forth-
with comply with such provisions or this permit shall be EVAPORATIVE COOLER VALIDATION
deemed revoked. j
FURNACE: FAU GRAVITY
' LICENSED CONTRACTORS DECLARATION FLOOR: BTU
I hereby affirm that I am licensed under provisions of Chapter HEATER: SUSPENDED UNIT t
9 (commencing with Section 7000)of Division 3 of the Busi- WALL -1
ness and Professions Code, and my license is in full force and
effect.
License Number �5 r/ Lic.Class
Contractor Lf v'r Date /L)
❑ I am exempt from the licensing requirements as I am a R
licensed architect or a registeted,professional engineer Plan check fee 25%of above.
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code). PERMIT ISSUING FEE$
Lic.or Reg.No. Date TOTAL FEE
I
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I
I hereby affirm that I am exempt from-the Contractor's NAME {
License Law for the following reason (Section 70.31.5, Busi-
ness and Professions Code): ADDRESS I
❑ 1, as owner of the property, will do the work and the i
structure is not intended or offered for sale (Section CITY TEL.NO.
7044, Business and Professions Code). I c A
❑ OWNER
I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project MAIL p
(Section 7044, Business and Professions Code). ADDRESS l!`91.!�% (�
CONSTRUCTION LLNDING AGENCY CITY 7- TEL.NO�
�� / o 0 1 ( ,, ,•.
I hereby affirm that there is a construction lending ag(!ncyr. 11 ^ '
for the performance of the work for which this permit is CONTRACTOR
issued Sec.3097,Civ.C.). !, y r)
Lender s Name ADDRESS
Lender's Address CITY
-7-L4 TEL.NO. L7
1 certify that I have read this application and state that the STATElj�i LIC.
above information is correct.I agree to comply with all County LICENSE NO. / CLASS
i
ordinances and State laws regulating Heating, Ventilating and
Air Conditioning,and hereby authori epresentatives of this SEE REVERSE FOIiF�YPLANATORY LANGUAGE
County to enter upon t abov - ntioned property for
it
1 ,
lure 06 f Permittee Date I
' I
76 A364- CE 818-1/75
APPLICA ON FOR PERMIT
HEATING - VENTILATING - AIR CONDITIONING
COUNTY OF LOS ANGELES BUILDING
DEPARTMENT OF COUNTY ENGINEER ADDRESS
BUILDING AND SAFETY DIVISION LOCALITY
NEAREST
CROSS ST.��iL/�GC Jy
FOR APPLICANT TO FILL IN OWNER
(PRINT OR TYPE ONLY)
MAI L
NO. TYPE&SIZE OF EQUIPMENT FEE ADDRESS GG)
SEE BACK OF APPLICATION
CITY TEL. NO.�'*-761 Y�
FORCE AIR FURNACE, BTU
CONTRACTOR
COMPRESSOR, BTU
ADDRESS 1
VENTILATION FAN
CITY v ?g�G TEL. NO.
LIST ALL OTHERS BELOW STATE,,l
LICENSE �
E NO. /OL5-y9 CLASS C
1l DI T ICT NO. GROUP ZONE PROCESSED BY
INSPECTION RECORD
IL
U
O
F
U
W
n.
Plan check fee. See reverse. z
Pf:R111T ISSI"I\C FIT: S
TOTA1, FEE a
PLAN CHECK APPLICANT
NAME
ADDRESS
CITY TEL.NO.
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL ORDINANCES AND LAWS REGULATING HEATING, VENTI-rNA
VALS DATE INSPECTOR'S SIGNATURE
LATING.AIR CONDITIONING.
I HEREBY CERTIFY THAT I AM NOT ACTIN VIOL ON �7
OF CHAPTER 9, DIVISION 3, OF T BU ESS A OFES NAL
CODE OF THE STATE OF LIF ♦ b
SIGNATURE ALIDATION •CK. M.O. CASH
OF PERMI I I E
PLAN CHEC AL1 ATION CK. M.O. CASH
21 9 GFR 17 4 1 1 2.0 0 end
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