HomeMy Public PortalAbout4905 ALESSANDRO AVE_Mechanical__ WORKERS COMPENSATION DECLARATION e` CE 6-18 q p 0Ct� ®fig FOR vll u
I hereby affirm that I have a certificate of consent to self 6� I5� C7
insure or a certificate of Workers Comp nsation Insurance or - HEATING_VE.NTILATING-Al ba CONDITIONING
W.I .
e�ptt!f 900 I^ )N /Co zany
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fied copy is hereby furnished ¢ —_ COUNTY OF LOS ANGELE � ` �t BUILDING AND SAFETY
Certified copy is filed with the county building inspection BUILDING
department _ FOR APPLICANT TO FILL IN ADORESs
Date Applicant (PRINT OR TYPE ONLY)
LOCALITY --�G
CERTIFICATE OF EXEMPTION FROM WORKERS NO TYPE OF APPLIANCE OR EQUIPMENT' FEE
COMPENSATION INSURANCE r NEAREST p }
(This section need not be completed if the work involved ABSORPTION UNIT BTU y CROSS ST � /�� //Z of O
by the permit is for one hundred dollars ($100) or less) - oisTRicT No PRor s5 .,BYU
I ceFtify that in the performance of the work for which this ° AIR HANDLING UNIT CFM f ti
`f permit is issued I shall not employ any person in any manner (� O
fi so as to become subject to the Workers Compensations Laws BOILER BTUU
z. APPROVALS 'D,A/TE I PECTOR S ATURE
f LU
Date Applicant COMPRESSOR BTU��_O_0��� BU 3 ZG� N
ROUGH
NOTICE TO APPLICANT If after making this Certificate of VENTILATION SYSTEM FINAL Z 1 p z
Exemption you should become subject to the Workers
Compensation provisions of the Labor Code you must forth
with comply with such provisions or this permit shall be EVAPORATIVE COOLER /1 /c� ALIDATION
deemed revokedFURNACE
LICENSED CONTRACTORS DECLARATION FLOOR BTUbOC� �d OO
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 I
License Number Lic Class a
Contractor Date
v
I am exempt from the licensing requiremtents as I am a
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 $ ''g9-
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 � Bust
ness and Professions Code) ADDRESS
I as owner, of the property will do the work and the CITY ` TEL NO
structure is not intended or offered for sale (Section
7044 Business and Professions Code) OWNER 2 4 O 9 6 A
I as owner of the property am exclusively contracting ti
with licensed contractors to construct the project MAIL # o a'o o 4
(Section 7044 Business and Professions Code) ADDRESS L?_o_ /r S S A/7 led
CITY TEL NO g 2 -,- 2700
CONSTRUCTION LENDING AGENCY / C 2 L
I hereby affirm that there is a construction lending agency CONTRACTOR �/ o'o'0`2 7 Q Q 6
for the performance of the work for which this permit is (7 L I
Wig_ O�
issued(Sec 3097 Civ C) D 5 '� � � s - 3
Lender s Name ADDRESS e�_O p lt�M` ./e 0 2 1 8—8
Lender s Address CITY ` /1� t— L/ JE!✓L NO Y
211 2 3 4!�
I certify that I have read this application and state that the STATE LIC ,7
above information is correct I agree to comply with all County LICENSE K02- Ilk � CLASS C�2�/
ordinances and State laws regulating Heating Ventilating and I I
Air Conditioning and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
County to enter upon the above mentioned property for `
i is ection purposes � e a '
Signature of Permittee Date