HomeMy Public PortalAbout9720 WORKMAN AVE_Mechanical__ JIVORKERS'COMPENSATION DECLARA'1 ION CEA 818C(2-80) fi\%P FIUC AT�ON FOR PER ILII T
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
'fl
a certified copy thereof(Sec. 3800,Lab.C.)
Policy No. Company
Certified copy is hereby furnished. COUNTY OF LOS ANGELE BUILDING AND SAFETY
Certified copy is filed with the county building,inspection BUILDING I
department. FOR APPLICANT TO FILL IN ADDRESS —
Date Applicant (PRINT OR TYPE ONLY)
LOCALITY t A— PL
CERTIFICATE OF EXEMPTION FROM�ti'ORKF RS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE L i"�
COMPENSATION INSURANCE NEAREST }
(This section need not be completed if the wort( involved ABSORPTION UNIT, BTU CROSS ST. � WE CLO
by the permit is for one hundred dollars (5100) or less.) -- — DISTRICT NO PRO' D 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
so as to become subject to the Workers'Compensation Laws. BOILER,BTU
APPROVALS DATE INSPECTOR'S SIGNA URE V
W
Date Applicant COMPRESSOR,BTU ROUGH _ N
NOTICE TO APPLICANT: If, after malting this Certificate of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers'
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 GRAVITY
LICENSED CONTRACTORS DLCLAR ATION FLOOR BTU
I hereby affirm that 1 am licensed under provisions of Chapter HEATER: SUSPEND Ir, N T
9 (commencing with Section 7000)of Division 3 of the Busi- WALL r
ncss and Professions Code, and my license is in full force and '
effect.
License Number Lic.Class
Contractor Date
El I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer Plan check fee_254o of above.
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code). t_
Lic.or Reg.No. Date 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
I, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section CITY TEL.NO. p C_ 1 7,2 A
7044, Business and Professions Code). OWNER l�Q `1 1 0 0 0 0 0 8
% G K PT
G;K1, as owner of the property, am exclusively contracting
with licensed contractors to construct the project AMAIL DDRESS 7 0 0 33.5 0
(Section 7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY TEL.NO. 0 0 0 3
I hereby affirm that there is a construction lending agency 204-8 1
for the performance of the work for which this permit is CONTRACTOR
issued iSec.3097,Civ.C.).
Lender s Name ADDRESS
Lender's Address CITY �L.N
I certify that I have read this 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 SEI: REVERSE FOR EXPLANATORY LANUUAGF
County to enter upVihe above-mentioned property for
in', inn pur os
Signa re of Per ittee bria