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HomeMy Public PortalAbout6042 ALESSANDRO AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION 7636 CEA 818 12-Ba> Q p p[���Q O foo p CS G3 0� I rzreby aNirm that I have a certificate of consent to self insure, or a certificate of Workers'Compensation Insurance,or CSIZATT . G-VEN70L.ATO.NG-G°OR CO(nl'D01T0®rf��l'Ofi�S a certified cop thereo Sec 500,Lab.C.) Policy No. company 41- 44AL ❑ Certified copy is hereby furnished. COUNTY OF ®S ANGELES BD.D00_®ONG AND SAFETY IN Certified copy is filed with the Lou y buildin inspect' n Fp�g APPLICANT TO MILL OfiO BUILDING ) /9N��d Date�de artme t. ADDRESS s a���dApplicant (PRINT OR TYPE ONLY) LOCALITY CERTIFICATE OF EXEMPT N FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE _ COMPENSATION INSURANCE NEAREST } ('This section need not be completed if work involved ABSORPTION UNIT, BTU CROSS ST. a0 by the permit is for one hundred ars ($100) or less.) DISTRICT NO. ! PRO r_.•;Eo B• V I certify that in the perfortrof the work for which this AIR HANDLING UNIT,CFM Q permit is issued, I shall not ploy any person in any manner . so as to become subject the Workers'Compensation Laws. BOILER, BTU APPROVALS DATE INSPECTOR'SSIGNATP iE W I Date pplicant COMPRESSOR, BTU 3 ©/Om Z) ROUGH N I` NOTICE TO PLICANT: If, after making this Certificate of Z Exemptio , you should become subject to the Workers' VENTILATION SYSTEM FINAL — Compe ation provisions of the Labor Code, you must forth- EVAPORATIVE C OLER VALIDATION de comply with such provisions or this permit shall be :..A � J deemed revoked. FURNACE. AU 7� GRAVITY 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 Busi- WALL ness and Professions Code, and my license is in full force and effect. .License NumberLie.Lia Class- �rO,.)-rIAL C Contractor r/J Date_ 7 ❑ I am exempt from the licensing requirements as I an a licensed architect or a registered professional engineer Plan check fee 25%Of above. acting in my professional capacity (Section 7051, Bus- iness and Professions Code). PERMIT OS UONG FEE $ Lic.or Reg.No. ate Y®FAQ_ (FSE „ �7 HOME OWNER-BUILDER 'CLARATION T I hereby affirm that I am ex npt from- the Contractor's ! #w/ ek& License Law for the following eason (Section 7031.5, Busi- ness and Professions Code): ADDRESS 66 V,Z / 4Z91-pS'/lIkil le ❑ .1, as owner of the pr perty, will do the work and the NO��QQ+ 9 structure is not int nded or offered for sale (Section CITY cl/ TEL. 7044, Business and rofessions Code). OWNER 2 3 5 i�7 A ❑ 1, as.owner of t'.e property, am exclusively contracting with licensed •ontractors to construct the project MAIL # 0:0 0,o (( } (Section 704 , Business and Professions Code). ADDRESS CO 'TRUCTION LENDING AGENCY CITY TEL. NO. 2 0•0 3 7.0 0 I hereby affi that there is a construction lending agency �� / tM :/� o 0 0 3 7,(l 0 for the per rmance of the work for which this permit is CONTRACTOR / /�5gt� �T� /I/ issued (Sec. 097,Civ.C.). ` / Lender's ame ADDRESS a0� C „ -t/,e.��a�.� / .12,29-80 Lender' Address CITY ;4N/4 //��� TE L.NO. 638-oZb�d I ce ify that I have read this application and state that the STATEI p LIC. cl�v ab a information is correct.I agree to comply with all County LICENSE NO. 6 p CLASS o inances and State laws regulating Heating, Ventilating and Conditioning, and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE o ty enter u on the�����jjjjjlbove-mentioned properly for insl a ai pur os � . S ature of Permittee Date