HomeMy Public PortalAbout6042 CLOVERLY AVE_Mechanical__ %16A364 �
WORKERS' at I h have
a7 certificate
1t2ATION ', E'-818 (2-80) G 1lI— It— L�� CAT 0 0 II�l FOR IP IEIFAS M ff
I hereby affirm that I Piave a certificate a eonsent••tc self
insure, or a certificate of Workers'Compensation Insui`ance,or HEATING-VENTILATING-AIR COHDOTI.O OM3
a certified copy thereof(Sec. 3800,Lab.C.)
Policy N0. �1`G�1rnpa11Y— �r�� _ COUNTY OF LOS ANGELES BUILDING ARID SAFETY
Certified copy is hereby furnished.
J Ceptified copy is filed with tt my b'rh n inspection r FOR APPLICANT TO FILL IN BUILDING � ���
le a-t >r
DatR27=\ _ Applicant_ _ _ _ (PRINT OR 7Y PE ONLY) ADDRESS
CERTIFICATE OF EXEMPTION+:ROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY
COMPENSATION INSURANCE NEAREST
(chis section need ,_o= be cor1'_r:eted I the -work involved ABSORPTION UNIT, BTU CROSS ST. d
by the perm,* is Fol cne J-u-1 TEG Collars ($100) or less..) DISTRICT NO. - PROCESSED BY CL
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM—
&
so as to become subject to the Workers' Compensation_Laws. 1I �
permit is issued, I shall not employ any person:in any manner
BOILER, BTU = O
APPROVALS YAT In`P 'TOR'S SIGN.TURE U
Date Applicant COMPRESSOR, BTU 0.
ROUGH _
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code,you must forth- I EVAPORATIVE COOLER VALIDA7IdN
with comply with such -provisions or this permit shall be
deemed revoked. FURNACE: FAU_ GRAVITY
LICENSED CONTRACTORS DECLARATION �—` FLOOR: TU
I hereby affirm that I am licensed under provisions of Chapter I HEATER: SUSPENDED UNIT
9' (commencing with Section 7000)'of Division 3 of the Busi- WALL
ness and Professions Code, and my license is in full force and I
LL—
effect.
License No b _ _ Lic.Class—:&A
Contractor_ Date
0 1 am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer 1j Plan check fee 25%-of above.
acting in my professional capacity (Section 7051, Bus- PERMIT ISSUING FEE $
iness and Pro'.ess'ons Code). l
Lic.or Reg.No. Date TOTAL EEE �
HOME OWNER-BUILDER DECLARATION I PLAN CHECK APPLICANT
I hereby affirm that i am exempt from- the Contractor's I NAME'
License Law for the following reason (Section 7031.5, Busi- z'4 2 7,,7 A
ness and Professions Code): ADDRESS
ElI, as owner of the property, will do the work and the `#.o.'o o'o.1..o 8
structure is not intended or offered for sale (Section i CITY TEL. NO. !
7044,Business and Professions Code). .-. 121
°�0 2 0 5 0
OWNER
I, as owner of the property, am exclusively contracting ko o"- 20,501
with licensed contractors to construct the project MAIL
(Section 7044, Business and Professions Code). ADDRESS 0 9.F1_9-8 4
CONSTRUCTION LENDING AGENCY CITY L'/ `,.�\ TEL. NO.
I hereby affirm that there is a construction lending agency �— p
for the performance of the work for which this
permit is I CONTRACTOR �'I_l./�U�\ y `
issued(Sec.3097,Civ.C.). \ ,\
Lender's Name ADDRESS
Lender's Address t
CITY '` TEL. NO.'�?
I certify that . have read this application and state that the STATESE f-s LIC.
above i 'ormatic n is correct.I agree to comply with all County I LIC
ENNO. �� CLASS
ordina -s and t tate 12 vs regulating Heating, Ventilating and
Air Cc it ming and reby authorize representatives of.this' SEE REVERSE FOR EXPLANATORY LANGUAGE
Coun' o ent. p i the above-mentioned property for
insp, s S. l`��/✓�/}�
Sio•_ h re of Permittee liate