HomeMy Public PortalAbout5836 ALESSANDRO AVE_Mechanical__ �,,l!��� 76A364C APPLICATION
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'WORKERS COMPENSATION DECLARATION 76 818 (2 80) A P D L IC A T 8 O �7 FOR PERMIT
rt��feut-affirm that I have a certificate of consent to self
insure or a certificate of Workers Compensation Insurance or HEATING-VENTILATING-AIR CONDITIONING
a certified copy thereof(See 3800 Laab�CC) "fl
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Policy No 0 0 Company���x a. FU h(�
Certified copv is hereby furnished COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with the county building inspection —
BUILDING
departm-nn+ IIXL��(=`�' FFOR APPLICANT TO FILL IN
Date t&1`1 Vim_ Applicant( U, �� �L ty2y (PRINT OR TYPE ONLY) ADDRESS
+ LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS NO TYPE OF APPLIANCE OR EQUIPMENT - FEE NEAREST �yJ�
COMPENSATION INSURANCE �T
(This section need not be completed if the work involved ABSORPTION UNIT BTU CROSS ST !U h' a
by the permit is for one hundred dollars ($100) or less) ++�� DISTRICT NO PROCESSBy Y O
I certify that in the performance of the work for which this AIR HANDLING UNIT CFMJroc)G aO �/ V
1
permit is issued I shall not employ any person in any manner D M
so as to become subject to the Workers Compensation Laws BOILER BTU 0
APPROVALS EYATE INSPE TOR >IG TURE V
Date Applicant COMPRESSOR BTU ROUGH d
NOTICE TO APPLICANT If after making this Certificate of VENTILATION SYSTEM FINAL
EVAPORATIVE COOLER L Z
Exemption you should become subject to the Workers
Compensation provisions of the Labor Code you must forth A VADA ION
with comply with such provisions or this permit shall be
deemed revoked - FURNACE FAU GRAVITY
F?0�:
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 WALL
ness and Professions Code and my license is in full force and _
effect //�� Q �,,//'� "
License NumberdlD&W613, Lie Class-4:40- 1 0 $R+
Contractoi( (/ Cl_Q4_ 11t�Date_/ `4/_9J ` # • • • • • $7
I am exempt from the licensing requirements as I am a j I °I° 3 Q 5 0 _
licensed architect or a registered professional engineer Plan check fee 25%of above 1 • • • 3 Q 5 0 c=�
acting in my professional capacity (Section 7051 Bus
iness and Professions Code) PERMIT ISSUING FEE $ I1 0 9=8'4
_ Lie or Reg No _ Date TOTAL FEE
HOME OWNER BUILDER DECLARATION PLAN CHECK APPLICANT,
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i
I hereby affirm°that I am exempt from the Contractors NAME .s
License Law for the following reason (Section 7031 5 Bust '
ness and Professions Code) ADDRESS a
i as owner of the property will do the work and the CITY
structure is not intended or offered for sale (Section TEL NO i r
7044 Business and Professions Code)
OWNER
O b
I as owner of the property am exclusively contracting
with licensed contractors to construct the project MAIL ��3[�
(Section 7044 Business and Professions Code) ADDRESS /Y f' la6�12L?
CONSTRUCTION LENDING AGENCY CITY I �1d4e, TEL NO -38
I r the performance
that there is a construction phis g agency e / � n
for the erformance of the work for which this permit is CONTRACTOR
issued (Sec 3097 Civ C) $y�$ S�al
t Lenders Name ADDRESS
Lender sAddress CITY TEL NO [�A�_^-1 J
I certifythat I have read this application and state that the ��n� 1 I //
Pp STATE LIC yti
above information is correct I agree to comply with all County LICENSE NO CLASS V
ordinances and State laws regulating Heating Ventilating and
r Air Conditioning and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
County to enter upon the above mentioned property for r
Ispechon purposes R Y
Signature of Permittee Dari - A M