HomeMy Public PortalAbout9073 WOOLLEY ST_Mechanical__ � ° 7bA31i" I� p ,q �p ® I� �,�I
WORKERS'COMPENSAT'ION DEC•j.AR�TIQ�V i CEI 716 • b 'A Ir P 1� C AT I O V FOR II'-E R tlVl) T
I hereby affirm that I have a, certificate o.f c' evit to'self,
insure,or a certificate of Workers'Compensation I ,uranc6,o-r HF -dENT 18_A tr lN�s-/�16� COIb®ITI®PII II�Gi
a certified copy thereof(Sec.3800,Lab.C.)
Policy Compan
El Certified copy is hereby furnished.y COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with the county building Inspection BUILDING
department. i FOR APPLICANT TO FILL IN
Date Applicant (PRINT OR TYPE ONLY) ADDRESS
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY C/Z
COMPENSATION INSURANCE NEAREST
(This section need not be completed if the work involved I ABSORPTION UNIT,BTU CROSS ST. C.,e a
by the permit is for one hundred dollars ($100) or less.) DISTRICT NO. PROCESSE U
I certify that in theerformance of the work for which this AIR HANDLING UNIT,CFM
permit is issued, I shall not employ any person in any manner `
so as to become subject to the Workers' Compensation Laws. BOILER,BTU 0
APPROVALS DATE IN R•S SI A V
Date Applicant COMPRESSOR,BTU ROUGH 1
d
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION.SYSTEM rA
Exemption, you should become subject to the Workers' FINAL
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDA ON
with comply with such provisions or this permit shall be
deemed revoked. FURNACE': FAU IGRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR. BTU
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.
License Number Lic.Class
Contractor Date
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 705.1, Bus-
iness and Professions Code), PERMIT ISSUING FEE $
Lic.or.Reg.:No. Date TOTAL FEE IS
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
i
I hereby affirm that I am exempt from-the Contractor's NAME eop e 1,.. We'gl
License Law for the following reason (Section 7031.5, Busi-
ass and Professions Code): ADDRESSId co
I, aS owner of the property, will do the work and the Q
structure is not intended or offered for sale (Section CITY TEL.NO.
7044,Business and Professions Code). `�� :`6 1 6 7 A
OWNER
I, as owner of the property, em exclusively contracting I -v
with licensed contractors to construct the project MAIL 1,4 0 0 0 0 0
(Section 7044,Business and Professions Code). ADDRESS /
CONSTRUCTION LENDING AGENCY CITY TEL.NO.. $S /'9 2 - - 38.50
I' hereby affirm that there is a construction lending agency -7 S; n s
for the performance of the work for which this permit is• CONTRACTOR o .0 0 L v
issued(Sec.309 i .
Lender's Name_ 7 I ADDRESS V21 0-82
Lender's Address e. aae h zG,� 1, CITY TEL.NO.
I certify that I have read. his application and .state. that the STATE LIC.
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 hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
County to enter upon the above-m!ntioV property for
inspection l+ noses.
ignature Per eel Datew