HomeMy Public PortalAbout5233 ALESSANDRO AVE_HVAC_7/30/1981_ WORKERS COMPENSATION DECLARATION 76A364C //�� �j(�p o
I hereby affirm that I have a certificate of consent to self CE 8t8 (2 80) G�1 U"" If- Lam, C Q T�®N FOR PER OVA T
insure or a certificate of Workers Compensation insurance or -HEATING_VENTIL.ATING-AIR CONDITIONING
a certified copy thereof(See 3800 Lab C) t
Policy No Company � r
Certified copy is hereby furnished COUNTY OF LOS AiUGELE�"/'%%� (" BUILDING AND SAFETY
Certified copy is filed with the county building inspection BUILDING
department FOR APPLICANT TO FILL IN
(
Date Applicant ADDRESS -'z��—�
a PRINT OR TYPE ONLY) l--
LOCALITY , —
C.ERTIFICATEOF EXEMPTION FROM WORKERS' NO TYPE OF APPLIANCE OR '(IUIPMFNT FEE
COMPENSATION INSURANCE — j- � �J NEAREST }
(This section need not be completed if the work involved /, ABSORPTION UNIT BTU�� v CROSS ST O/�.f _— (�- a
by the permit is for one hundred dollars (SI00) or less) DISTRICT NO 1 N 1PR0D BY -
I certify that in the performance of the work for which this AIR HANDLING'UNIT CFM 9
permit is issued I shall not employ any person in any manner �/ I
so as
tto beco nef subject to the Workers Compensation Laws BOILER BTU APPROVALS DATE INSPECTORSSIGNATURE F-
I Date L 9_V{_Applicant_ _ _ COMPRESSOR BTU 4 w CL
t ROUGH
E NOT1( E TC APPLICANT If f r n }it h i -rtificate of VENTILATION SYSTEM FINAL z
Exemption you should bei o v b r co th Workers
Compensation provisions of the Labor Code you must forth
with comply with such provisions or this permit shall be EVAPORATIVE COOLER VALIDATION
deemed revokedx
FURNACE FAU GRAVITY � 7��
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 Bust
ness and Professions Code and my license is in full force and
Lieffect �14
License Number Lic Class_
Contractorm-AV kJ .� Date ` Z o / J
—�/
I am ekempt from the licensing requirements as I am a r
licensed architect or a registered professional engineer Plan check fee 25%of above
acting in my professional capacity (Section 7051 Bus '
mess and Professions Code.) PERMIT ISSUING FEE $ 71_�)
Lie or Reg No Date TOTAL FEEj
HOME OWNER BUILDER DECLARATION PLAN CHECK APPI (CANT i
I hereby affirm that I am exempt from the Cdntractor s NAME'-_r_? �� _ 1 3 7 3 A
License Law for the following reason (Section 7031 5 -Buri ` v �TTx"C
ness and Professions Code) ADDRESS (� 8i
��1_E���� _ vC ccocc
I as owner of the property will do the work and the + 2 e ro 2 3
structure is not intended or offered for sale (Section CITY ^_ _ rc� TEL NO S�/ ? r
00
7044 Business and Professions Code) .1` - \ �-`p OWNER io)o Je 2 3 O O U
x
I as owner of the property, am exclusively contracting
with licensed contractors to construct the project MAIL 7 (� ( ,A` _' 0 9 2 9—8 1
(Sect on 7044 Business and Professions Code) ADDRESS
CONSTRUCTION LENDIISG AGENCY CITY^._ �(� C TEL NV'1 7Q� 0�4
i
I hereby affirm that there is a construction lending agency ��``������i�JJ C-tJV i
for the performance of the work for which this permit is CONTRACTOR t �
issued(Sec 3097 Civ C) J l <<
Lender s Name ADDRESS
Lender s Address CITY „ (�r TEL NOJI
2rTC'�_iCS�
I certif that I have read this application and State that the STATE AA
LIC 1•
aitces
tion is correct I agree to comply with all County LICENSE NO �j _ _�� CLASS
od State laws regulating Heating Ventilating and �Amg and hereby authorize representatives of thts SEE REVERSE FOR EXPLANATORY LANGUAGE
Ci to u)on the above mentioned property for
u � _SgreoPermittee Date
F