HomeMy Public PortalAbout6217 CLOVERLY AVE_Mechanical__ RKERS'COMPENSATION Dl Ci.ARATjtilhi• f� + CE-1311CPP
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`%er6by affirm that I have a certificate of consent,to self CE g18 (2 80) /� l����� u V If l�If\S IVU ��
insure, or a certificate of Workers'Compensatib,.Insurairi:,or HEATING-VENTILATING-AIR CONDITIONING
d certified copy thereof(Sec 3800,Lab C) LJ
Policy No7Z7J,7 ��03Comp,anyfNSI[2 C4
❑ Certified copy is hereby furnished COUNTY OF LOS ANGELES BUILDING AND§AFETY
R1 �epart department
is filed with the county budding Inspection FOR APPLICANT TO FILL IN BUILDING
department wn�7"es /✓ 6-�r
Date ��1'y Applicant_✓ / (PRINT OR TYPE ONLY) ADDRESS 7
LOCALITY /
CERTIFICATE OF EXEMPTION FROM WORKERS' NO TYPE OF APPLIANCE OR EQUIPMENT FEE �/1td e
COMPENSATION INSURANCE NEAREST /
(This section need not be completed if the work involved ABSORPTION UNIT, BTU CROSS ST 1�L Ae/i% 4
by the permit is for one hundred dollars ($100) or less) DISTRICT NO PROCEO
I certify that in the performance of the work for which this Al R HANDLING UNIT,CFM ry V
permit is issued, I shall not employ any person in any manner Cx/ Q:so as to become subject t0 the Workers' Compensation Laws BOILER, BTU O
APPROVALS DATE INSPEC OR S SIGN URE V
Date Applicant COMPRESSORBTU 3�0;OOO - .1 - - 4
,
ROUGH
NOTICE TO APPLICANT If, after making this Certificate of VENTILATION SYSTEM FINAL Z
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- I
EVAPORATIVE COOLER VALID TION'
with comply with such provisions or this permit shall be
deemed revoked
LICENSED CONTRACTORS DECLARATION, I FURNACE FAU (o0,-MTQ
FLOOR BTU_�jQ_ — IT
I hereby affirm that I am licensed under provisions of Chapter HEATER SUSPENDED UNIT
9 (commencing with Section 7000) of Division 3 of the Bu$i- WALL
ness and'Professions Code,and my license is in full force and
effect �/ C 3$ Sc oto
License Number /0373S L,C Cldss se Vy :2 31 38 A
Contractor_66_N6!�'Z r7/C Date O # o o a o o8
❑
I am exempt from the licensing requirements as I am a
0 0
licensed architect or a registered professional engineer Plan check fee 25%of above 2 r 3 Q
acting in my professional capacity (Section 7051, Bus-
iness 'Lo and Professions Code) PERMIT ISSUING FEE $ 1_6 , ,
xu
Lic or Reg No Date TOTAL FEE 0,$ 0 1 -8 4
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT �
I hereby affirm that I aril exempt from the Contractor's NAME
Lu.ense Law for the following reason (Section 7031 5, Busi-
ness and Professions Code) ADDRESS
1, as owner of the property, will do the work and the CITY TEL NO
structure is not intended or offered for sale'(Section
7044,Business and Professions Code)
❑ OWNER
I, as owner of the property, am exclusively contracting �L ¢ A 2 S �'e
with licensed contractors to construct the project MAIL
(Section 7044, Business and Professions Code) ADDRESS ��� �(/e t!!/_,-__ V-3
CONSTRUCTION LENDING AGENCY CITY 7`P�e�� ��• TEL NO � }�>C71—/7/ F
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is CONTRACTOR�ONya� /� fir• G
issued (Sec 3097,Civ C) Alen'/�
Lender's Name ADDRESS Yc 7
Uy �/1rCr Yi
Lender's Address CITY7P�o/� Cry TEL NO 02(/3
I certify that I have read this application and state that the STATE // LIC X38 S(Co20
above information is correct I agree to comply with all County LICENSE NO o 37 3� CLASS S !�/
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
into ction purposes
SignaOire of Permittee Date