HomeMy Public PortalAbout9924-9926 WOODRUFF AVE_Mechanical__ WORKERS'COMPENSATION DECLARATIC+.ta CE-81 C APPLICATION FOR PERMIT
1 hereby affirm that I have a' certificate of consent to self CE 8 8(2.80)
insure, or a certificate of Workers'Compensation Insurance,or HEATING-VENTILATING-AIR CONDITIONING
a certified co Cher 3800,Lab.C.) u
tL—Oe VOWPolicy Nis. Company__A2&�JbtDitf T
COUNTY OF LOS ANGELES BUILDING AND SAFETY
E3 Certified copy is hereby furnished. •
Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN BUILDING
Date iie. ^Applicant 0-A co, (PRINT OR TYPE ONLY) ADDRESSj�."�
71�1-
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY J TCZV
COMPENSATION INSURANCE NEARESTA �''A
(This section need not be completed if the work involved ABSORPTION UNIT,BTU CROSS ST. U' iYvrJ CL
by the permit is for one hundred dollars ($100) or less.) DISTRICT NO. PROCESSFD BY_ U
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM
permit is issued, I shall not employ any person in any manner >> 0
so as to become subject to the Workers'Compensation Laws. BOILER, BTU
�¢•�: APPROVALS DATE INSPECTOR'S SIGNATURE .V
Date Applicant COMPRESSOR,BTUAIJAMI
ROUGH
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM
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Exemption, you should become subject to the Workers' FINAL ... �. N
, —6„d. - Z
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU AVITY
LICENSED CONTRACTORS DECLARATION FLOOR; BTU =0C"
I hereby affirm that I am licensed under provisions of Chapter HEATER: SUSPENDED UNIT
9 (commencing with Section 7000)of Division 3 of the Busi- WALL
ness and Professions Code, and my license is in full force and
effect. p -1
License Number / Lic.Class
,-�
Contractor Date,(J1�1��
❑ I a e. mpt from the licensing requirements as I am a
licensed architect or a registered professional engineer Plan check fee 25%of above.
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code): PERMIT ISSUING FEE$ >T
Lic.or Reg.No. Date I TOTAL FEE -
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from- the Contractor's NAME
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): ADDRESS
❑ 1, as owner of the property, will do the work and the CITY TEL.NO.
structure is not intended or offered for sale (Section 7 2 2 e A
7044,Business and Professions Code).
❑ OWNER
I, as owner of the property, am exclusively contracting ��+r � '• n o 0 0 o R
with licensed contractors to construct the project MAIL �y /� �-y�
(Section 7044, Business and Professions Code). ADDRESS 7 (o 1�' ��'�� o o b R J 0
CONSTRUCTION LENDING AGENCY CITY T:- 4Dre„7-- r TEL.NO.aaI6--if)/-:�
I hereby affirm that there is a construction lending agency CONTRACTOR
for the performance of the work for which this permit is 4M Z %'9' �d�r� `
issued Sec.3097,Civ.C.). 1 0 2 9 �• �
Lender s Name ADDRESS665- S- ?—Uer
Lender's Address CITY/J4D/V1,(0 70f TEL.NO.70
I certify that I have read this application and state that the LIC.
above information is correct.1 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 enter upon the above-mentioned property fok
i�tsppettiop pyrpose. N
Signature of Permittee Date