HomeMy WebLinkAbout1592A (9)WORKERS' CO%IPENSATION DECLARATION
1 hereby affirm that I have a' certificate of consent to self
insure, or a certificate of workers' Compensation Insurance, or
a certified copy thereof (Sec. 3800, Lab. C.))
Pulley No. —2G6 (K Cnmpany_ZQ-
E] Certified copy is hereby furnished..
�crtified copy is tiled with The county building inspection
V�
Dale Applicant_ _
CIiRTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the work involved
by the permit is for one hundred dollars (S100) or less.)
I certify that in the performance of the work for which this
permitis. issued, I shall not employ any person in any manner
So as to become subject to the Workers' Compensation Laws.
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption, you should become subject to the Workers'
Compensation provisions of the tabor Code, you must forth.
with cmnPly with such provisions or this permit shall be
deemed revoked.
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter
9 (enmmencing with Section 7000) of Division 3 of the Busi-
ness and Professions Code, and my license is in full force and
effect. �J�� {t �pp� ^
I icense Numbcaq�,�5jC_.6 �.. Lic. Clas((s�� —.J-0
tractnrrl�_V�()1J-Qf Date _p_Z
UI am pt from the licensing requirements as I am a
licensedexemarchitect or a registered professional engineer
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code).
Lic. or Reg, No. Date
HOME OWNER.BUILDFR DECLARATION
I herebv affirm that I am exempt from- the Contractor's
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code):
❑ 1, as owner of the property, will do the work andthe
structure is not intended or offered for sale (Section
7044, Business and Professions Code).
❑ 1, as owner of the property, am exclusively contracting
with licensed contractors to construct the project
(Section 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is
issued (Sec. 3097, Civ- C.).
Lender's Name
Lender's Address
1 certify that 1 have reaLI this application and state that the
above information is correct. I agree to comply with all County
ordinances and State laws regulating Heating, Ventilating and
Air Conditioning, and hereby authorise representatives of this
County to enter upon the above-mentioned property for
inspect., n urpo-�s
Lf
Signature I Permittee Date
CE" -8;8D(2 -BO) APPLICATION FOR PERMIT
HEATING-VENTILATING-AffR CONDITIONING
1COUNTY OF LOS ANGELES U, S� `abs BUILDING AND SAFETY
a --3a 6 q
FOR APPLICANTTO FILL IN
(PRINT OR TYPE ONLY)
BUILDING I D5 n_1
ADDRESS j'C II__11 11 l� F
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
LOCALITY
NEAREST
CROSS ST.
ABSORPTION UNIT, BTU
AIR HANDLING UNIT, CFM
DISTRICT N0,
?
PP.00ES Ep eY
/j 7
BOILER, BTU.r
COMPRESSOR, BTU �OlM0 l
APPROVALLSS GATE In' fCTOR's SIGNATURE
ROUGH
FINAL✓'
VENTILATION SYSTEM
EVAPORATIVE COOLER
VALIDATION
5159.2A
� :, �.8
I --53.25
e e n 5 3.2 O v
oaz0-83
1 FURNACE: FAU— RAVITY �O.
LOOR:
` FLOOR:—
HEATER: SUSPENDED UNIT
HEATER:
AALL�
WALL
_
Plan check fee 25% of above.
PERN11TISSUING FEE S O S
TOTAL FEE �3a
PLAN CHECK APPLICANT
NAME
ADDRESS
CITY TEL. NO.
OWNER 3raG
MAIL
ADDRESS �fi_J�—Lt=V
CITY TEL: NO.
CONTRACTOR—g6(
ADDRESS
CITYn.�pp TEL.NO.STA
,,C,:,.,!TE NO• . �6 LLI CLLI C.
CLASS
SEE REVERS17 FOR 17XPLANATOIZY LANGUAGE
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