HomeMy Public PortalAbout5802, 5808-10 ALESSANDRO AVE_Mechanical__ 1 nn p y� -yam � �bM �y�w '(�✓T
WORKERS COMPENSATION DECLARATION 76Aa364C
CE 818(2 80) A P P F—C A II �®N FOR P E R UGp T
hereby affirm that I have a Certificate of consent to self
insure or a certificate of Workers Compensation Insurance c �� I-IE�+YIWCy_bEWTILl�YIWG-�►IL@ C�Ri®IYIO�IWGi
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❑ Certified copy is hereby furnished COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with the county building inspection _ BUILDING
denartrrien FOR APPLICANT TO FILL IN
Date UO DMA4 ApphcantWilpac Plumb3-ng-,Inc (PRINT OR TYPE ONLY) ADDREss580 Alessandro Ave_
CERTIFICATE OF EXEMPTION r' OM WORKERS NO TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITTEmple Cit
CERTIFICATE Or Or EXE�MPTIIONN rl 0 WORKERS
COMPENSATION INSURANCE NEAREST }
(This section need not be completed if the work involved ABSORPTION UNIT BTU cRoss ST Workman Ave 0
by the permit is for one hundred dollars ($100) or less) DISTRICT NO �i PR L)
JiL� U
I certify that in the performance of the work for which this AIR HANDLING UNIT CPM j �^1 J�j CC
permit is issued I shall not employ any person in any manner ( (f Q
so as to become subject to the Workers Compensate n I aws IBOILER BTU I—
Date O Applicant__ APPROVALS DATE INSP CT R GNATURE W
�a _&�?p AAJ — COMPRESSOR BTU ROUGH
NOTICI
T(/APPLICANT If after in kin this Certificate ofTt0N SYSTEM Z
Exemption you shouldllsu t too the Workers FINAL
Compensation provisions of the Labor Code you must forth EVAPORATIVE COOLER '
with comply with such provisions or this permit shall be VALIDATION
deemed revoked ° a FURNACE ' FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter_ HEATER SUSPENDED UNIT Jv�
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 2 35M BTU Wall Furnaces 20 00
i icense Nn her19g3129 Lie Class C-36 ,
Wilpac P1umbing,InC 10-3-84 X0851 A
Contractor Date
❑ , # • 060 • 8
I am exempt from the licensing requirements as`I am a a
licensed architect or a registered professional engineer Plan check fee 25%of above
acting in my professional capacity (Section 7051 Bus I o o 3 Q 5 0
mess and Professions Code) I PERMIT ISSUING FEE $ 10 50
Lie or Reg No Date TOTAL FEE 30 50 µ Y
o o s 3 a 5 0 cii
HOME OWNER BUILDER DECLARATION
PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractors NAME . 1 0, 10—. 84
License Law for the following reason (Section 7031 5 Busi "
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 o x
7044 Business and Professions Code) 1
❑ ,
I as owner of the property am exclusively contracting OWNER
�.
with licensed contractors to construct the project MAIL
(Section 7044 Business and Professions Code) _ ADDRESS
` CONSTRUCTION LENDING AGENCY CITY ' TEL NO
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is CONTRACTOR Wilvac Plumbin I
issued (Sec 3097 Civ Cp g�
AC.
) o y q
Lender s Name ADDRESS14225 S Halldale Ave
Lender s Address a CITY Gardena -TEL NO 779-0742 r
I certify that I have read this application and state that the SATE LIC
above information is correct I agree to comply with all County LiCE SE NO 193129 CLASS C+-36
ordinances and State laws regulating Heating Ventilating and 4
Air Conditioningand hereby authorize representatives of this
p SEE REVERSE FOR EXPLANATORY LANGUAGI•.
County to enter upon the above mentioned property for
Inspection purposes
�1A-3-84
Signatu �,.tteDate _