HomeMy Public PortalAbout4815 ALESSANDRO AVE_Mechanical__ WORKERS COMPENSATION DECLARATION CEA 8 8C(2 80) APPLICATION FOR P E R UVU T
I hereby affirm that I have a certificate of consent to self ,
insure or a certificate of Workers Compensation Insurance or } C-4E�►TING-bENT IL�►YIW�v-A16d CONDITIONINGa cert fled copy thereof(Sec 3800 Lab C)
Policy No Company z
Certified copy is hereby furnished "'
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with the count) building inspection BUILDING
dP ar men �y �" y1 /� FOR APPLICANT TO FILL IN ADDRESS Dater�_��G�Applicant X� /�� (PRINTaOR TYPE ONLY) 14� "/�,
CLRTIFICATE OF EXEMPTION FROM WORKERS
NO TYPE'OF APPLIANCE OR EQUIPMENT FEE LOCALIT���^� y
COMPENSATION INSURANCE NEAREST >-
(This section need not be completed if the work involved ABSORPTION UNIT BTU CROSS ST O
by the permit is for one hundred dollars ($100) or less) DISTRICT NO PROCESSED By U
I certify that in the performance of the work for which this AIR HANDLING UNIT CFM �� O
permit is issued I shall not employ any person in any manner r +may
so as to
become subject to the Workers Compensation Laws BOILER BTU APPROVALS GATE INSPECTORS SIGNATURE r (~)
Date_ ��Applicant /"'L� �"j!i W
COMPRESSOR 8TU ROUGH O-
_ N
NOTICE TO APPLICANT If after making this Certificate of VENTILATION SYSTEM FINAL Z
Exemption you should become subject to the Workers
Compensation provisions of the Labor Code you must forth EVAPORATIVE COOLERVALIDATION M
with comply with such provisions or this permit shall be `
deemed revokedFURNACE FAU rP4VITw
Y
LICENSED CONTRACTORS DECLARATION - FLOOR BTU t � 45;7 .r
I hereby affirm that I am licensed under provisions of Chapter HEATER SUSPENDED UNIT
9 (commencing with Section 7000) of Division 3 of the Busi WALL
ness and Professions Code and my license is in full force and s
effect 21�;
� 7STSr��si s
License Number// ,-/JZ Lie Class_ISJ /
Contractoxc(5 /56me- Date— I/
i am exempt from the licensing requirements as I am a
licensed architect or a registered prof€ssional engineer Plan check fee 25%Of above
acting in my professional capacity (Section 7051 Bus
iness and Professions Code) PERMIT ISSUING FEE$
_Lie or-Reg No Date- /�/� TOTAL FEE
HOME OWNER BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractors NAME -
License Law for the following reason (Section 7031 5 Busi `
ness and Professions Code) ADDRESS `
1 as owner of the property will do the work and the TEL NO
structure is not intended or offered for sale (Section CITY
7044 Business and Professions Code) ` OWNER 2 4 4 4,0 A
O �� 66
1 as owner of the property am exclusively contracting �•Y #i o ore o o 8
with licensed contractors to construct the project MAIL
(Section 7044 Business and Professions Code) ADDRESS ��� 7f�i 2fo - 301
5 0
�a TEL NO q L,/�G
CONSTRUCTION LENDING AGENCY CITY � 4/ pf 0 a l0 3 0 6 0
I hereby affirm that there is a construction lending agency °
for the performance of the work for which this permit is CONTRACTOR /�Aa
issued (Sec 3097 Civ C) `�/-vj 0 8 1 1 -+813
Lenders Name ADDRESS L/�`„ / f LS
Lender s Address CITY /��fVl4, -GJ/ TEL NO
I certify that I have read this application and state that the STATE
above information is correct I agree to comply with all County LICENSE NO
----M-ordinances and State laws regulating Heating Ventilating and
Air Conditioning and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE w
County a ter upon th above mentionLd property for
uispP +i0 pu aosP
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Sig aiure of Permittee Date _ _