HomeMy Public PortalAbout5934, 5934 1/2 ALESSANDRO AVE_Mechanical__ 'WORKERS COMPENSATION DECLARATIOD;y CE b1 C APPLICATION
P p 8C A T I O S t�O R PERMIT
lid M OT
c CE b18 (2 80) If- IL.� i"i u �t7 If If�S If� UY Y�%0
I hereby affirm that I have a certificate of consent to self f
insure or a certificate of Workers Compen,atton Insurance or i HEATING VENTILATING-AIR CONDITIONING
a certified coov thereof(Sec 3800 Lab C)
5 .`i�' tC� } t
6,f.3�1 7 �cE,� I
Policy No Company
❑ COUNTY OF LOS ANGELES T - BUILDING AND SAFETY
Certified copy is hereby furnished
� Certified copy is filed with the county building inspection BUILDING
department �,,, A FOR APPLICANT TO FILL IN ADDRESS
Date_f-�f!a YAPPIIcant (PRINT OR TYPE ONLY) ----
LOCALITY
CERTIFICATE OF EXEMPTION PROM WORKERS NO TYPE OF APPLIANCE OR EQUIPMENT FEE
COMPENSATION INSURANCE NEAREST ! >_CROSS ST d
(This section need not be completed if the work involved ABSORPTION UNIT BTU 2_44.- -� a 0
by the permit is for brib hundred dollars ($1,00) or less) - DISTRICT NO PROCESSF BY V
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 S v 00
sq as to become subject to the Workers Compensation Laws BOILER BTU
APPROVALS DATE INSPECTOR S SIGNATURE tCLU
Date Applicant COMPRESSOR ROUGH -/ ^^o- '4- N
NOTICE TO APPLICANT If after making this Certificate of VENTILATION SYSTEM
Exemption you should become subject to the Workers FINAL
Compensation provisions of the Labor Code, you must forth EVAPORATIVE COOLER VALIDATION
with comply with such provtsions or this permit shall be"
deemed revoked FURNACE FAUX GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU000— D �/i
I hereby affirm that I am licensed undei provisions of Chapter HEATER SUSPENDED UNIT V
_9 (commencing with Section 7000)of Division 3 of the Bust WALL
ness and Professions Bode and my license is in full force and
effect r7Y
2 a
License Number_, /7_9_V OLic Class »
Contractor_ Date_Z�=/ S-y
❑ i
I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer Plan check fee 25%of above
actiril, in my professional capacity (Section 7051 Bus �a a
mess and Professions Code) PERMIT ISSUING FEE $/p
Ltc or Reg No Date TOTAL FEE
HOMEOWNER BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractors NAME - }/IG
License Law for the fallowing reason (Section 7031 5 Busi
ness and Professions Code) , ADDiRESS
-S'337 �J 0C42--) 90503A
❑ I as owner of the property will do the work and the �+ TEL NO �f' �/ t# a o i o�o o $
structure is not intended or offered for sale (Section CIT. 0 1 o(O��i�/d
i r
7044 Business and Professions Code) 1 . 2 -1- 405,0
❑ OWNER
I as owner of the property am exclusively contracting VV II
with licensed contractor, to construct the project ( MAIL / °1 oo 4 0 5 0 c=>
(Section 7044 Business and Professions Code) ADDRESS -5- ?3(o t
CITV`�I�i, n�n TEL NOgk&-77eV 0'4,-,l6-84
CONSTRUCTION LENDING AGENCY - � `r"`''r
I hereby affirm that there is a construction lending agency
for the performance of the Work for which this permit is CONTRACTOR
issued(Sec 3097 Civ C
Name
Lender s Nme ADDRESS � y
Lender s Address CIZ r� TEL NO
I certify that I have read this application and state that the STATE //-7!J g�Q LIC -��
above information is correct I agree to comply with all County LICENSE NO OC !7 CJ V 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
uisoection purpo s
Signature of Permittee Date