HomeMy Public PortalAbout5031 ALESSANDRO AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION 76A364C /,I, n IPp C n T�O H FOR
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I hereby affirm that I have a certificate of consent to self CE -818(2-80) /tel I� L� G S Uli IfJ U1S CGU
insure, or a certificate of Workers'Compensation Insurance,or
a certified thereof(Sec. 38y00,L )
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Compan
COUNTY OF LOS ANGELES BU11 LD1lN v AND SAFETY
Certified copy is hereby furnished.
Certified copy is filed with the county building inspection
FORAPP�DIrANT TO HILL UN BUILDING /
Ippartment. ADDRESS �Q 3 N/ '�/,wu4)CD_
Date``G=SA Applicant_t_`± - (PRINT OR TYPE ONLY).
LOCALITY 1
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE � �f ! y
COMPENSATION INSURANCE NEAREST
CROSS ST. (( d
(This section need not be completed if the work involved ABSORPTION UNIT, BTU O
by the permit is for one hundred dollars ($100) or less.) DISTRICT NO, PROCESSED aY 0
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM �^'\ cc:
permit is issued, I shall not employ any person in any.manner i r O
so as to become subject to the Workers' Compensation Laws. BOILER,BTU _ V
' APPROVALS DATE TINSPECTOR'SSIGNATURE
Date Applicant i I COMPRESSOR, BTV_ o�a� (� 1 ROUGH 4-10, -•�,j �
NOTICE TO APPLICANT If, after making this Certificate of I VENTILATION SYSTEM FINAL —// _ a.+ 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
deemed revoked. FURNACE: FAU GRAVITY -
LICENSED CONTRACTORS DECLARATION l FLOOR: BTU- 'gd.Q— ��
I hereby affirm that I am licensed under provisions of Chapter HEATER: SUSPENDED UNIT
9 (commencing with Section 7000)pf Division 3 of the Busi- WALL
ness and Professions Code„and my license is in full force and
effect. v7�/
License Number-.2_/1 6WO Lic.Class lam'c;L V
ContractorDate
QI am exempt from the licensing requirements 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-
iness
us- i �l�ff�Ii1i�� OSS��4�lO ���
inessand Professions Code). I
Lic.or Reg.No. Datef TOTAL FEEQ1 .
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from-the Contractor's NAME Q d- E�r 4 0 3 36 A
License Law for the following reason (Section 7031.5, Busi- =-r__& m �. +►,CI
ness and Professions Code): j ADDRESS Lj 7 ,a�(� ,4_0 o'o(o o 8
1, as owner of the property, will do the work and the }
structure is not intended or offered for sale Section 7-_FC_W t TEL.NO. 2 °`° 30,50
7044, Business and Professions Code), p /�, Cl °`.° o` s
OOWNER /��S' (✓+t {,�pfVy�e a . i r`3�1,:J��c�
1, as owner of.the property, am exclusively contracting, I �!/'�
with licensed contractors to construct the project t MAIL 0. 0 9'-to 4
(Section 7044,•Business and Professions Code). ” ADDRESS�v� /l�_�/�hEss/�/(�Fi��
CONSTRUCTION LENDING AGENCY CITYTEm RAE c`+�/ TEL.NO.a�s —/2,0
I hereby affirm that there is a construction lending agency CONTRACTOR 1` .( [
for the performance of the work for which this permit is .
issued(Sec. 3097,Civ.C.).
Lender's Name ADDRESS
I
Lender's Address l CITY TEL.NO. ,
I certify that I have read this application and state that the I STATE v. 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 , SEE REVERSE FOR EXPLANATORY LANGUAGE
County to enter upon the above-mentioned property for
inspection purposes.
t4T
Signature of Permittee Date