HomeMy Public PortalAbout5233ALESSANDRO AVE_HVAC WORKERS COMPENSATION DECLARATION a CEA 818 C(2 80) ��i"J�B®1�1 ®� I� Il�u ��
I hereby affirm that I have a certificate of consent to self l
insure or a certificate of Workers Compensation Insurance or } (��A1IN(y-bENT1LAYINC�-�i� CONDITIONING
a certified copy thereof(Sec 3800 Lab C)
Policy No Company h
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Certified copy is hereby furnished COUNTY OF LOS ANGELES ( - BUILDING AND SAFETY
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Certified copy is filed with the county building inspection Z
department a FOR APPLICANT TO FILL IN ENEA
ILDING ✓�
Date Applicant (PRINT OR TYPE ONLY) DRESS ✓ l_—r ,�
CALITY
CERTIFICATE OF EXEMPTION FROM WORKERS NO TYPE OF APPLIANCE OR EQUIPMENT s FEE 1 ! —
COMPENSATION INSURANCE REST ' / � �(This section need not be completed if the woik involved ABSORPTION UNIT BTU OSS ST V IRl O
by the permit is for one hundred dollars ($100) oI less) DISTRICT NO PROCESSED BY '1 V
1 certify that in the performance I f L e work for which this AIR HANDLING UNIT CFM ,Q CC
permit is issued I shall not em ii, ny perste in any manner J i Q`� 0
so as to eco a Subject to the Vv er C ensation Laws BOILER BTU l—
a APPROVALS DATE INSPECTOR S SIGNATURE (�
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Date _ Applicant, _ COMPRESSOR BTU ROUGH �Z3 '� a_
NOTIC TO \PPLICANT If after making this Certificate of VENTILATION SYSTEM Z
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 provisions or this permit shall be
deemed revoked FURNACE FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter HEATER SUSPENDED UNIT C!
9 (commencing with Section 7000) of Division 3 of the Bust ' WAL
Hess and Professions Code, and my license is m full force and �x `1\y
effect
License Nu�b=— Lic Class BContractor _ Date-71-
I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer Plan check fee 25%of above p
acting in my professional capacity (Section 7051 Bus
iness and Professions Code) PERMIT ISSUING FEE $ 71
Lw or Reg No Date TOTAL FEE
Ix 3LL-
HOME OWNER BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractors NAME
License Law for the following reason (Section 7031 5 Busi r
ness and Professions Code) ADDRESS
I as owner of the property,will do the work and the Y ` TEL NO
structure is not intended or offered for sale (Section CIT
7044 Business and Professions Code) OWNER ))) 20,57 5 A
I as owner of the property am exclusively contracting __
with licensed contractors to construct the project MAIL # o o,o'olo 8
(Section 7044 Business and Professions Code) ADDRESS _
I
CONSTRUCTION LENDING AGENCY CITY k,�__�` _ TEL I J 2 01'0 1 3J 0 0
I hereby affirm that there is a construction lending agency 1C `
for the performance of the work for which this permit is CONTRACTOR��� �o�o II e i� 3 0 0 5
v
issued(Sec 3097 Civ C) {—— a c , w
Lender s Name ADDRESS L — t 0,73,10-8
Lender s Address CITY TEL NO ����j(/yj Q `
`•--I� C�]
I certify that II have read this application and state that the STATE LIC I
abo Ii oration is correct I agree to comply with all County 11 LICENSE NO � = CLASS
—��
ordi a ces nd State laws regulating Heating Ventilating and
Air i ditic nmg id hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
Co n } to n e pon the above men toned property for
In ae t I p
S e ature )r Permittee I ate