HomeMy Public PortalAbout5802, 5808-10ALESSANDRO AVE_Mechanical (5) WWORKERS'COMPENSA i IORT DECLARAT.IrA `CEA 9.8 C(2-80) Q p p UC Q Ti �O N U OO R p E RWT
I hereby affirm that I have a' certificate of consent to self
insure, or a certificate of Workers'Compensation Insurance,or HEATQNG.VENTILATING-AIfRt CONDITION OMG
a certified copy thereof(Sec. 3800,Lab. C.)
Policy No. Company
Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
l lI Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN BUILDING ���{�,{�,,n�T
deo_rt*rPpn*. U/GOA ADDRESS r�2 ACE5 /r i09Z
Date 0RIL L Applicant—ACM0 (PRINT OR TYPE',ONLY) -
LOCALITY .ry1u_I(j(� C/ CA4/r-,
CERTIFICATE OF EXEMPTION FROMWORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
COMPENSATION INSURANCE NEAREST >-
(This section need not be completed if the worlt involved ABSORPTION UNIT, BTU CROSS ST. 0-
by the permit is for one hundred dollars ($100) or less.) DISTRICT NO, PROCESSED BY 0
I certify that in the performance of the work for which this I AIR HANDLING UNIT,CFM cc
permit is issued, I shall not employ any person in any manner 0
so as to become subject to the Workers' Compensation Laws. BOILER, BTU
APPROVALS DATE INSPECTOR'SSIGNATURE tU
Date Applicant COMPRESSOR,BTU ROUGH - C/)
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM ✓ FINAL -/ z
Exemption, you should become subject to the Workers'
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: SU —Pr NDED UNIT
9 (commencing with Section 7000) of Division 3 of the Busi- I - LL
ness and Professions Code, and my license is in full forcd and
effect. tU J Q p
License Numbeer—°� _ �f Lic.Class
ContractorAEA 6Wt10LA5 Date -
® I am exempt from the licensing requirements as I am a V
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 ISSUING EEE $
Lic.or Reg.No. Date TOTAL 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 Cod--): ADDRESS
1, as owner of the property, will do the work and the e
structure is not intended or offered for sale (Section CITY TEL. NO. �6'4 I,3 A
7044, Business and Professions Code).
O OWNERool0 0 0 8
m
I, as owner of the property, aexclusively contracting ,
with licensed contractors to construct the project MAIL 2;0 0 2 a-5 0
(Section 7044, Business and Professions Code). ADDRESS
CONSTRUCTION LENDING AGENCY CITY TEL. NO. o 0 .2',a 6 0 C5
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is CONTRACTOR �(/GQC'IES 0 92,41-
-8 2
issued (Sec. 3097.Civ.C.).
Lender's Name ADDRESS qS- 6AP
Lender's AddressCITY (� CaUa/NR TEL. NO. IWO
I certify that I have read this application and state that the STATE c[ �(S- LIC.
above information is correct.I agree to comply with all County LICENSE NO. z F 3 T CLASS g_ '
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
inspection roses.
_
Signature of Permit,/ Date