HomeMy Public PortalAbout5133 CAMELLIA AVE_Mechanical__ r` WQRkERS'CQMPENSATION DECLARATION CEA 8 SC(2 SO) APPLICATION 1-" O R PERMIT'
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1 hereby aflNrm tha[j1 have r certificate of consent to self
Insure, or a certificate of Workers'Compensation Insurance,or HEATING-VENTILATING-AIR CONDITIONING
a certifledcopy the f(Sac."3806,Lab. C.)
Policy No �mp�,y_�"[; EO
❑
Certlfled copy is hereby funvlahal. .COUNTY OF LOS ANGELE �j BUILDING AND SAFETY
.r� � � $.� ,
Ifled copy Is filed with the count),b Tiding Inspection�� p FOR APPLICANT TO FILL IN BUILDING •-�r�
Date��'! _ Applicant (PRINT OR TYPE ONLY) ADDRESS J J
CERTIFICATE OF EXEMPi_IO FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE' LOCALITY
COMPENSATION SURANCE NEAREST s > oc A,
(This sectloa need not be coUnploted if the work luvolved ABSORPTION UNIT, BTU C-ROSS ST.
by the permit is for one hundred dollars ($10(1) or less.) DUrMICrNO. v
I certify that in the performance of the work for which this AIR HANDLING UNIT CFM /T�� cc
permit Is issued, I shall not employ any person in any manner v
so as to become subject to the Workers' Compensation Laws. tBOILER, BTU
APPROVALS DATE INSPECTOR'S 9taNATURE pW.
Date_ Applicant GtOMPRESSOR BTU ROUGH fJ�
"NOTICE TO APPLICANT: If, aft er.mak Ing this Certificate of VENTILATION SYSTEM FINAL Z
Exemptlon, you should become subject to the .Workers'
Compensation provisions of pmEVAPORATIVE COOLER the Labor Code, you must forth- �y� ALIDATION
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU GRAVITY
'LICENSED CONTRACTORS DECLARATION FLOOR: BTU
I hereby affirm that 1 am licensed under provisions of Chapter HEATER: SUSPENDED UNIT
9 (commehcing wlth,Section 7000) of Division 3 of the Bust- WALL
ness and Professions Code, and my license is in•full force and
effect. •
License Numbe�✓SZgSy Lic.Class ,
�! Contractor Date r Z ,
aI am exempt from the licensing roquirements as I ■m a
licensed architect or ■ registered professional engineer Plan check fee 26%of above.
acting In my professional capacity (Section 7051, Bus-
iness and Professions Code). PERMIT ISSUING.FE`E $
Lic.or Reg.No. Date TOTAL FEE
HOME OWNER-BUILDER DECLARATION
PLAN CHECK APPLICANT
r
I hereby affirm' that I ■m exempt from- fhe Contractor's NAME �► 3.2 Q b A
License Law for the following reason (Section 7031.5, BussCAA-
Hess and Professions Code): ADDRESS # o,olo o o 8
❑ 1, as owner of the property, will do the work and the
structure V not Intended or offered for sale (Section - CITY TEL. NO:Z$-��� 2:0j- 1 65 0
7044, Blnslness and Professions Code). a 2
El 1, as owner Of theproperty, OWNER ` o(o.0 1 t`1 50U
am exclusively contracting
with licensed contractors to construct the project MAIL
(Section 7044, Business and Professions Code). ADDRESS 'S I 0 33.!0 9,8 2
CONSTRUCTION LENDING AGENCY CITY %96Z Se—
TEL..N
I •hbreby affirm that there Is a construction lending agency CON7RACT0
for the performancd of the work for which this permit is
rmw
issued tSec. 3097,Civ.C.).
Lender.s Name ADDRESS
Lender's Address CITY %Q,E' TEL.NO.
.l certify that I have read this application and state that the 2 $ LIC
BTATE .
above Information is correct. 1 agree to comply with all County E b7 LASS
ordlnances and State Inws regulating_1-teating, Ventilating and
Air Conditioning, and hereby authorize representatives of this - SEE REVERSE FOR'EXPLANATORY LANGUAGE
County to enter upon the abov entioned property for
his n p rpos y
Z "
nature of Per ittee Date