HomeMy Public PortalAbout6036 CAMELLIA AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION CEA 618 C(2-80) A P P S BC AT S O N FOR P E R R� T
I herebf affirm ,that I have i certificate of consent to self .
Insure, or ■ certificate hereo (Worker'Compensation Insurance,or HEATING-VENTILATING-AIR CONDITIONING
¢certified copy thereof(Sec. 3800,Lab. C.) � LJ
Policy No. Company
❑ Certified copy is hereby f6mished. COUNTY OF LOS ANGEL �C:�,
BUILDING ARID SAFETY
❑ Certlfled copy Is filed with the county building Inspection BUILDING
. department. FOR APPLICANT TO FILL IN
Date Applicant (PRINT OR TYPE ONLY) ADORE
Date
LOCALIT
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
COMPENSATION INSURANCE NEAREST
his section need not be completed if the work involved ABSORPTION UNIT, BTU CROSS ST
(T
by the permit.is for one hundred dollan ($1()0) or less.) oIaTRICTH P
_ I certify that In the performance of the work for which this AIR HANDLING UNIT,CFM J�
permit is issued, I shall not employ any person In any manner c�
so as to become subject to the Worker' C p Ion Laws. BOILER BTU
APPROVALS DATE IPWECTogpalaH� RE.
Date- ppllcant. �, i^^+ 4 COMPRESSOR BTU, ROUGH d
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM fn
Exemption, you shpuld bbcome subject to the Workers' FINAL - Z
-Compensation provisions of the Labor Code, you must forth-
Nvith comply with such. provlsfons or this permit shall be EVAPORATIVE COOLER VALIDATION
deemed revoked.
LICENSED CONTRACTORS DECLARATION FURNACE: FAU GRAVITY
FLOOR: BTU
T hereby affirm that [ em-licensed under provisions of Chapter HEATER: SWQ46V D U IT vl/
9 (commencing with Sectibn 7000) of DiviWon 3 of the Busl- ALL
nese and Professions Code, and my license is In full force and
effect.
License Numb Lic. Class—&
ContractDate ���5 �--
❑ 1 am exempt from the licensing requirements as I am a
licensed architect or ■ registered professional engineer Plan check fee 26% of above.
acting In my professional capacity (Section 7051, Bus-
fnes¢and Professions Code). . PERMIT ISSUING FEE $
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, Bust- 2'S 5 4 A
naso and-Professions Code): . ADDRESS .
❑ 1, as owner.of the property, will do the work and the # a e o • o8
structure Is not intended or offered for sale- (Section CITY TEL. NO.
7044, Business and Professions Code). OWNER 2'• • 2 a 5 0
❑ I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project MAI L o e -23506
(Section 7044, Business and Professions Code). ADDRESS
CONSTRUCTION LENDING AGENCY CITY TEL. NO. 1,Q7�82
I hereby affirm that there is a construction lending agency
for the performanFe of the work for which this permit Is CONTRACTOR �s
Issued (,Sec.3097,Civ.C.).'
eec
Lender.s Name ADDRESS
n Y
Lender's Address CITY �r� At
TEL. NO.s,
I certify that I have read this application and state that the STATE L LIC.
above information is correct.I agree to comply with all County' N CL
ordinances and State laws regulating Heating, Ventilating and
Alr Conditioning, and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
County t upon the ova-mentloned property for
Inspect) pur J rJ�
Sigfiature of Per ttee Data