HomeMy Public PortalAbout9932-9934 WOODRUFF AVE_Mechanical__ 1' 76A364C pp I.I Y�l f ® PERMIT _
WORKERS'COMPENSATIONDECLARATJ_N " I 'CE-818'(2-80) APPLICATI® r'®R PERMIT
I hereby affirm that I have a' certificate of consent to self.
insure, or a certificate of Workers'Compensation Insurance,or
HEATING-VENTILATING-AIR CONDITIONING
a certified co xther, f �c.3800,Lab:C.)
Policy No. 'fid Company- D�1(7 7; ,
Certified copy is hereby furnished. I
COUNTY OF LOS ANGELES BUILDING AND SAFETY
I
Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN BUILDING Q�j �I�
Dat de Applicant to
nty. (PRINT OR TYPE ONLY) ADDRESS 4, R— /! 3 WA6FT
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY
COMPENSATION INSURANCE NEAREST 40 ,n >_this section need not be completed if the work involved' ABSORPTION UNIT, BTU CROSS ST. K/ a
by the'permit is for one hundred dollars ($100) or less.)" DISTRICT NO, PROCESSE BY V
I certify that, in the performance of the work for which this AIR HANDLING UNIT,CFM
permit is issued, I shall not employ any person in any manner s C� Cc
so as-to become subject to the Workers'Compensation Laws. BOILER, BTU.
1� APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant vc� COMPRESSOR,BTU - 7 ROUGH ��z a
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM �. ._`7 Cn
Exemption, you should become subject to the Workers' FINAL r ( (�
Compensation provisions of the'Labor Code, you must forth- DATION
with comply with such„ EVAPORATIVE COOLER VALI
provisions or this permit shall 'be ' � �1' ,
deemed revoked. FURNACE: FAU ITY .
LICENSED CONTRACTORS DECLARATION FLOOR: BTU ,all
I hereby affirm that I am licensed under provisions of Chapter HEATER: SUSPENDED UNIT �) 'J
9 (commencing with Section 7000)of Division 3 of the Busi- WALL
ness and Professions Code, and my license is in full force and
effect.
License NumberLic.Class Ca ` 1
Contractor lO_qw.l .�-� Date �[ O��Y '4 y
F1 I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer Plan check fee 25%of above.
acting in my professional capacity (Section 7051, Bus- ) �'
iness and Professions Code). PERMIT ISSUING FEE$ ~� -T(1, �Z
.Lic.or-Reg.No. Date TOTAL FEE SO
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
I, as owner of the property, will do the work and the' �•7 2 2.9 A'
structure is not intended or offered for sale (Section CITY TEL.NO.
7044,Business and Professions Code).
El I, as owner of the property, am'exclusively contracting OWNER JA0J. t. �r p G'6 R 0 s
with licensed contractors to construct the project MAIL pp
(Section 7044,Business and Professions Code). ADDRESS �- ���� -� hLf 10.'29-82
CONSTRUCTION LENDING AGENCY - CITY -/]I 0& -GT . TEL.NO.� � �
I hereby affirm that there is a construction lending agency CONTRACTOR
for the performance of the work for which this permit isL
issued(Sec.3097,Civ.C.).
Lender's Name ADDRESS44105- S. �vY
Lender's Address CITY 0[1=A" TEL.NO."_6XI "
I certify that I have read this application and state that the, STATE �y CLASS a�
above'information is correct.I agree to comply with all County LICENSE NO.
ordinances and State laws regulating Heating, Ventilating and
Air Conditioning,and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
County to enter�A�
ove-mentioned property for
ill tion pL,_
Signature of Permittee Date 3