HomeMy Public PortalAbout6019 CLOVERLY AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION 76A364C
I hereby affirm that I have a certificate of consent to self CE 81 B (2 80) A P P UC A T�ON FOR i!— E R Vv%p .0
insure, or a certificate of Workers'Compensation Insurance,or p. IEATINCy_yEN'TILAYIN(y_A1R CONDITIONING
a certified cop til �fe� 3800, I ab C)
Policy N��'`Y j �-Company �'�]r�"�'/".r,`-
Certified copy is hereby furnished j µ COUNTY OF LOS ANGELES �� BUILDING AND SAFETY
�I Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN BUILDING o i j�
epartment ADDRESS /1/
Dat ' Zr Applicant / (PRINT OR TYPE ONLY)
LOCALITY
CERTIrICATE 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 d
by the permit is for-one hundred dollars ($100) or less) DISTRICT NO PROCESSED BY U
I certify that in'the performance of the work for which this AIR HANDLING UNIT,CFM (� Ix
permit is issued, I shall n �
not employ any person in any manner i Ua O
so as to become subject to the Workers' Compensation Laws BOILER, BTU F-
- APPROVALS DATE INSPECTOR S SIGNATURE (�
Date Applicant COMPRESSOR,BTU 3(� yu y Iv u w
ROUGH US
NOTICE TO APPLICANT If, after making this Certificate of VENTILATION SYSTEM FINAL — 7"
Exemption, you' should-become subject to the Workers
Compensation provisions of the Labor Code, you must forth VALIDATION
with comply with such EVAPORATIVE COOLER
provisions or this permit shall be
deemed revoked FURNACE FAQ RAVITY
LICENSED CONTRACTORS DECLARATION FLOOR B /o CSC7 ao3
i hereby affirm that I am licensed under provisions of Chapter HEATER SUSPENDED UNIT
9 (commencing with Sbctton 7000) of Division 3 of the Busi WALL „r
ness and Professions Code, and my license is in full force and 90 ' 7 �K
effect I
License Number Lic Class
Contractor Date
lam exempt from the licensing requirements as I am a
licensed architect or a registered'professional engineer Plan check fee 25%of above
acting in my professional capacity-(Section 7051, Bus
mess and Professions Code) PERMIT ISSUING FEE $ Od
Lic or Reg No Date TOTAL FEE '7
i
HOME OWNER BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's NAM C,PA-License Law for the following reason (Section 7031 5, Bust
ness and Professions Code) ADDRESS
1, -as owner of the property, will do the work and the
structure is not intended or offered for sale (Section CIT TEL NO 2`0 0 2 6 A
7044, Business and Professions Code)
OWNER
I, as owner of the property, am exclusively contracting Lio(0
with licensed contractors to construct the project 1 MAIL ��t [ L U
(Section 7044, Business and Professions Code) ADDRESS (J � ev
_ o oto 2 7 0 0
fi
CONSTRUCTION LENDING AGENCY CIT1f TEL NO' ,y -71
- 01622-81
I hereby affirm that there is a construction lending agency �-
for the performance of the work for which this permit is CONTRACTOR
issued Sec 3097,Civ C)
Lender s Name ADDRREE.SSSS 7,3
Lender's Address CITY /-�� TEL NOO
I certify that I have read this application and state that the STATE/ IC,/- I Q LIC
above information is correct I agree to comply with all County LICENSE NO 7o 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
uisection purp ses
Cif /1•
10.4 ( —Z-Z=-
Sig an ture of Permittee _ Date