HomeMy Public PortalAbout5337 BARELA AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION 7BA384C pp {� p /� w' FOR
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I hereby affirm that I have a' cnrtlficete of co����pp,t to sn11 I. CE -818 (2-8b) Psi I!— P ILi iC P1 T I b 1�4 r O R P E R�0 �T
insure, or a certificate of Workers'Compensation lniiu'rance,or "ti' `"` HEATING-VENT ILATING-AIJR CONDITIONING
e certified copy thereof(Seq.-3800,j.ab. C.)
Policy No. Corppany
k ❑ Certified copy is hereby furnlahed. COUNTY OF LOS ANGELES 7t d-'( BUILDING AND SAFETY
Certified copy le filed with the county building Lnspection �~
department. FOR APPLICANT TO FILL IN BUILDINQ �y O A
Date .Applicant (PRINT OR TYPE ONLY) ADDRESS S 33'7 19Ir IJ Vt
• LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE,
COMPENSATION JNSUA
RNCE NEAREST Q _
(This section need not be completed If the work involved � ABSORPTION UNIT, BTU CROSS ST. f V
by the permit is far one hundred dollar ($100) or lens.) DI9 Ft ICT NO, PROCMED y
Icertify that In the performance of the work for which this AIR HANDLING UNIT CFM
permit is issued,J shell not employ any person In any m4nrnay O
so as to become subject to the Workers' Compensation Laws.' BOILER BTU
L'� APPROVALS DATE INaFFCTO R'S AIeN AT IRS
Date SL'Appllcan C brM P FFE SS
OR BTU O d O EIOUGiI LII
NOTICE TO APPLICANT: If, Aer making this Certlficate of VENTILf4TION SYSTEM FINAL Z
1 Exemption, you should become subject to the Workers
I Compensation provisions of the Labor Code, you must forth-
with comply with such provisions or thLs Permit shall be EVAPORATIVE COOLER VALIDATION
deemed revoked,
FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR: BTU
7 hereby affirm that I am licensed under prbvfslons of Chapter HEATER: SUSPENDep UNIT f
9 (commencing with Section 7000)of Division 3 of the Busl- WALL
news and Professions Code, and my license Is in full force and
effect.
License Number—' Lic.Class
Contractor Date
❑ 1 am-exempt from the licensing requirements'" 1 em s
Ilcehsed architect or a registered professional engineer. Plan ChQek fee 25%of Above.
acting in my professional capacity (Senior 7051, Bus-
Lness and Professions Code). PERMIT ISSUING*FEE$ Q
Lic.or Ree.No. Date TOTAL FEE Q
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT 10'6 1.2'A
I hereby affirm that I am exempt from- the Contractor's NAME Eu —d�l� #}jo 0 o e 8
License Ldw for the fqllowing reaspn (Section 7031.5, Bust-,
nese nd Professions Code): lo,o-
j ADDRESS S 3 LL+ !'} U 2� 1 3.Q6 O
LF ', as owner of the property, will do the work and the 4 )
structure Is not intended,or offered for sale (Section CITY _ fi TEL.NO. o • 0 3 a�5 0.H
7044, Business and Professions Code). + J r
❑ I, es owner of the OWNER O L� 9—8 4
property, am exclusively contracting
with licensed contractors to construct the project MAIL
- (Section 7044, Business and Profesaioes Code). ADDRESS —
CONSTRUCTION LENDING AGENCY CIT -�- TEL.NO. g
I heteby afflrm that there .H a construction lending aydncyy
for the performance. of-the work for which Chia permit Is CONTRACT R
issued (Sec 3097,Civ.C.). .
Lender's Name • ADDRESS
Lender's Address CITY E.L.NO.
I certify that L have read.this application and state that the STATE LIC.
above Ln-rormatlon is correct. I agree to comply with all Cypnty 61QENSg NQ. CLASS
ordinances and State laws regulating Heating. Ventilating add
Air Conditioning, and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
County to enter upon the above-mentioned property for
in ctlon purposes. ,
Signs a of Permittee Data.