HomeMy Public PortalAbout6046 CAMELLIA AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION CEA 64 (2 80) APPLICATION FOR Il— IER M 7
I hereby affirm that I have ¢ certificate of.consent to self
insure, or a certificate of Workers'Compensation Insurpada,or HEATING-VENTILATING-AIR CONDITIONING
a certifled copy thereof(Sec. 3800,Lab.C.)
Policy No. Company
❑ Certified copy-is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
❑ Cartlfled copy is filed with the county building inspection •
department. FOR APPLICANT TO FILL IN BUILDING
Date Appllcarit (PRINT OR TYPE ONLY) ADDRESS
CERTIFICATE OF EXEMP'T'ION FROM-WORKERS'
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY
COMPENSATION INSURANCE NEAREST }
('This wedon need not be completed if the work involved ABSORPTION UNIT, BTU CROSS ST, a
by the permit is'for one hundred dollars (;100) or lose) DISTRICT ED BY
I certify that in the performance of the work for whlctr this AIR HANDLING UNIT CFM oil
permit is issued, I shall not employ any pprspn In any manner vi O
w as to become subject to the Workers' Compensation Laws. BOILER BTU
APPROVALSI LU
DATE I ECTOR'a SIQNATURI
Date AppHcant COMPRESSOR BTU
• ROUGH
NOTICE TO APPLICANT: It after making this Certiflate of VENTILATION SYSTEM Z
Exemption, you should become sub_lect to the Workers' FINAL
Compensation provisions of the Labor Code, you mtist forth-
with comply with such proVdalons or this permit shall be EVAPORATIVE COOLER Vd'inATIOrr
deemed revoked. FURNACE: FAU GRAVITY—
LICENSED ZONTRACTORS
RAVITYLICENSEDZONTRACTORS bECLARATION FLOOR: BT
I hereby affirm that I am licensed under provlslons of Chapter HEATER: SUSPENDED UNIT
9 (commencing_withSection 70.00) of Division 3 of,the Busl- WALL
ness and Professiom
ru CoAe., ind r-llcense is in full force and
effect.
Licence NumberT Llc.Class
Contractor Date
❑ I am exempt from the liepnsing requirements as I am a
li
censed' architect or a registered professional egglneer Plan:dieck.fee•25%of above.
acting to my professional capacity (Section 7051, Bus-
West and Professlorts Code). PERMIT ISSUING FEE
Lic_or Ret.No. Date TOTAL FEE _
HOME OW-9ER-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- - r
nest and Professions Coda): ADDRESS ACCT■
❑ 1, as owner of the Property, will do the work and the �a �y
structure is not Latenddp or offered for nate (Section CITY TEL. NO. ...__.. Ti■W
7044, Business and Profosslons Code). 1 ITM
011OWI, as owner of the property, am exclusively contracting
NER '
4�1pvith licensed contractors to construct the project MAILTOTAL 48 00
(Section 7044, Business and Professions Code). -AD-DRE-3s44(- L J CWCK 48.00
CONSTRUCTION LENDI)gG AGENCY CITY7i�041 TEL.NO
I hereby affirm that there Is a construction lending agency, • I 0
for the performance•of the work for whicli this permit is CONTRACTOR
Issued(Sec. 3097,Civ.C.). ��//++��LL �pp
Linder Name ADDRESS 1AJVIJ-Owl IU24/07
Lender's Address CITY TEL.NO. 6364 rJ LMJ i e�:25
07
I certify that I have read this application and state the the. STATE LIC. 1 7
above information is correct.I agree to comply with ail County ENSE N Q. CLASS
ordinances and State laws regulating Heating, Ventilating end
Air Conditioning, and hereby au-thorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
Co my to nter upon the above-mentioned property, for
I pos
, z ,
Ignat 1 to