HomeMy Public PortalAbout6048 CAMELLIA AVE_Mechanical__ 7f5
WORK> RS'COMPENSATION DECLARATION CEA 818 C(2-80) APPLICATION r O R PERMIT
I hereby affirm that I have a certificate of consent to self
Insure, or a cerdf]cete of Workers'Compensation Insurance,or HEATING-VENTILATING-AIR COI�dDITIOWIiVG
■certified copy thereof(Sec.3800, Lab.C.) 4
Policy-No. Company
El Certified copy U hereby furnished.
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is flied with the county building Inspection �f
department.
FOR APPLICANT.TO FILL IN BUILDING
Date Applicant (PRINT-OR TYPE ONLY) ADDRESS
IL
LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NO, TYPE OF APPLIANCE OR EQUIPMENT FEE
COMPENSATION INSURANCE. NEAREST
(This section need not be completed If the work involved ABSORPTION UNIT,-BTU CROSS ST. >.
by the permit is .for one hundred doUus ($100) or less.) I DISTRICT NO. w �+/ PROC eD ev S
I certify that In the performance of the work for which this AIR-HANDLING UNIT,CFM
permit Is Issued, I shall not employ any person in any manner �� M
to as to become subject to the Workers' Cornportsatlon,Laws. BOILER BTU— d
APPROVALS DATE INSPECTORaSIflMATURe
" Date Applicant COMPRESSOR BTU ff) ROUGH
NOTICE TO APPLICANT: If, after making this Certificate ofVENTILATION SYSTEM
FINAL Z
Exemption, you should become subject to the Workers' _
Compensation provisions of the Labor Code, you must forth-
with comply with such provisions or this permit shall be EVAPORATIVE COOLER VALIDATION
deemed revoked.
LICENSED CONTRACTORS DECLARATION FURNACE: FAU GRAVITY
FLOOR:— BT
I hereby affirm that I am licensed under provisions of Chapter HEATER: SUSPENDED UNIT
9-(commencing with Section '7000) of
Division 3 of the Busl- WALL
neas and Professions Godo, and my license Is In full force and
effect.
License Numbef Lic.Class—
Contractor
la s-Contractor Date-
1 am exempt from the licensing requirements as I am a
Ilcenaed architect or a reglatered professional engineer Plan check fee 25% of above.
acting in my professional capacity (Section 7051, Bus-
iness
uriness and Professions Cade). 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 fallowing reason (Section 7031.5, Buii-
nese and Professions Code): ADDRESS CCT■T ��yy�yy
1'. .La owner of the property, will do the work and the 3M7 TQ■W
sructretia not intended 'or offered for Lala (Section CITY TEL. NO..
7044,1usinoas and Profes3ions Code). OWNER -^ 1. IT� �iti Y U 1,7
as owner of the.property, am exclusively contracting TINAL AL 48. oo
th Ilcensed contractors to construct the project MAIL
( iop 7044, Business and Professions Code). ADDRESS
CC.• ECY 9vaSJL�
CONSTRUCTION LEN-DING AGENCY CITYTL TEL.NO. 7� 41 ry�
I hereby affirm that there is ■ construction lending agency aw
for the performance of the work for which this permit Is CONTRACTOR
Issued (Sec. 3097,Cly.C.).
Lender's Name AbDRE!SS
00OD-OW1 10/24/89
Lender's AQdress CITY TEL.NO. 1 ~' 7
AM p_
STATE LIC
1 certify that I have read this application and state that the .
r
above information is correct. 1 agree to comply with all County LICENSE NQ. CLASS
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
hu tlo u
gnaturo o t Date