HomeMy Public PortalAbout6028 CLOVERLY AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION CEA3B64BCI2 80) A (ice fl'��'� ®fa FOR
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I hereby affirm that I have a certificate of consent to self b"�1 If-" II E�I If— If�S Ir Lam.Il1S II\/p U
insure, or a certificate of Workers'Compensation Insure ce,or HEATING-VENTILATING-AIR CONDITIONING
a��c�p�tlte,eof(Sec 3800,L � ���`
Policy o l Company T,c
El Certified copy is hereby furnished COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with the county building inspection BUILDING
Y� art en . ` K- ,� n FOR APPLICANT TO FILL IN
Date Applicant
LTU/(.G�_ (PRINT OR TYPE ONLY) ADDRESS Q
LOCALITY%_G';i a
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 CROSSST O
1 by the permit is for one hundred dollars ($100) or less) - DISTRICT NO PROCESS BY 0
I (,ertify that in the performance of the work for which this AIR HANDLING UNIT CFM6-1 O� O
permit is issued, I shall not employ any porson in any manner
so as to become subject to the Workers' Compensation Laws BOILER BTU
,,ni APPROVALS DATE INSPECTOR$SIGNATURE W
Date Applicant / COMPRESSOR �
,BTU0_l t�� �� OQ ROUGH N
NOTICE TO APPLICANT If, after making this Certificate of VENTILATION SYSTEM FINAL z
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth EVAPORATIVE COOLER VALIDATION
with comply with such provisions or this permit shall be
deemed revoked FURNACE FA L WRAVITy
LICENSED CONTRACTORS DECLARATION FLOOR BT D dO 15-211/
-
I hereby affirm that I am licensed under provisions of Chapter HEATER SUSPENDED UNIT
9 (commencing with Section 7000) of Division 3 of the Busi WALL 4
ness and Professions Code and my license is in full force and t
effect `p(� '
License Number" a Lie Class d
Contractor Date '�2
I am 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-
iness and Professions Code) 7
00
Lie or Reg No Date TOTAL FEE, RZ OU
HOME OWNER BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that_I am exempt from the Contractor's - NAME' L.
License Law for the following reason (Section 7031 5, Busi-_
ness and Professions Code) ADDRESS''
I, as owner of the property, will do the work and the CITY TEL NO`' 0 3 IL 5 A
structure is not intended or offered for sale Sectionw[[ "��
7044, Business and Professions Code)
OWN?Rt4�JI, as owner of the property, am exclusively contracting
with licensed contractors to construct the project MAIL _2{° ° 2 7 0 0
- (Section 7044, Business and Professions Code) ADDRESS
CONSTRUCTION LENDING AGENCY CI TEL NO a�/� 8U3 °j° ° 2 Q O
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is CONTRACTO �� 0 7,1 5—8 1
issued (Sec 3097,Civ C)
Lender's Name ADDRESS 6-9 3 7
Lender's Address CIT 7t 0- TEL NO,� -2��
i certify that I have read this application and state that the STATE �7 (� LIC /� a
above information is correct I agree to comply with all County LICENSE NO / O CLASS Cs
ordinances and State laws regulating Heating, Ventilating and
Air Conditioning, and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
County toenter �ryup/�on��the above mentio//ned properly for
ii ctwwurp° S L
7_ -SI J -
Signature of Permittee Date