HomeMy Public PortalAbout5218 ARDEN DR_Mechanical__ WORKERS'COMPENSATION DECLARATION CEA 818(2-80) 1�l Ir" II- UC G=ET�O N FOR USS If`E R IIVIf M
I t-,,reby a.irm that I have'a certificate of consent to self
insure, or a certificate of Workers'Compensation Insurance,or X[EATING_V ENTIL.ATING-AIR CONDITIONING
a certified copy thereof(Sec.3800,/�Lab.
C.)�� 1�7
Po4�! 1d � 26' 3 Company_�l�^-f �`,v C, /
El Certified copy is hereby furnished..
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with th-count;building inspection BUILDING
d rt,,� ,t j� � FOR APPLICANT TO FILL IN
Date_ _ Applicant- __ _ V_X�' (PRINT OR TYPE ONLY) ADDRESS )�' r
-� LOCALITY. IG.�L_�
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
COMPENSATION INSURANCE NEAREST �/
CROSS STW16 rn�� }
(This section need not be completed if the work involved ABSORPTION UNIT, BTU [ �1/ tl
by the permit is for one hundred dohars ($100) or less.) DISTRICT NO. PROCESSED By 4 0
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM r D�
permit is issued, I shall not employ any person in any manner a cc
so as to become subject.to the Workers' Compensation Laws. BOILER, BTU0
APPROVALS DATE INSPECTOR'S SIGNATURE V
Date Applicant -� ROUGN /� c' � d
COMPRESSOR,BTU
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL U Z
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE CO OLE VALIDATIQN
with comply with such provisions or this 'permit shall be
deemed revoked.
FURNACE: 'FAU l
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter HEATER: SUSPENDED UNIT /�
9 (commencing with Section 7000) of Division 3 of the Busi- WALL Qf,?T
ness and Professions Code, and my license is in full force and
effect. 21Z�
License Number I;21SUN
Lic.Class
42
Contractor a.I�G6/uV t..%in to
I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer Plan check fee 25%of above.
acting in my professional capacity (Section 70S1, Bus-
iness and Professions Code). PERMIT ISSUING FEE$
Lic.or Reg.No. DateTOTAL FEE
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt .from- the Contractor's NAME
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): ADDRESS
QI, as owner of the property, will do the work and the TEL. NO.
structure is not intended or offered for sale (Section CITY 2'5'8 18 A
7044,Business and Professions Code). rD
�p
❑ OWNER 5
I, as owner of the property, am exclusively contracting +o o o•0 0
with licensed contractors to construct the project MAIL v
(Section 7044,Business and Professions Code). ADDRESS _ Z o'o 4,450
CONSTRUCTION LENDING AGENCY CITY TEL.NO. (j,r( � )o`o io 4 5 0 U
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is CONTRACTOR , � Q 5,_8
issued(Sec. 3097,Civ.C.). G
Lender's Name ADDRESS
Lender's Address CIT• TEL..N 7�
a G
I certify that I have read this application.and state that the STAT, /�� LIC.
above information is correct.I agree to comply with all County LICENSE NO. _�ly CLASS _
ordina ces and State laws regulating Heating, Ventilating and
Air C(nditionir and hereby authorize repres?ntative of this SEE REVERSE FOR EXPLANATORY LANGUAGE
Coun y e .ter u on th. above:,mvs
d pro erty for
u spe aic r poses j}s�
�natl re of P nitteo/ U Da,/-