HomeMy Public PortalAbout6229 CLOVERLY AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION CEA gt g f2-80) Q 1I!— LL= C G�1��O u�l FOR IT-"E R�j T
I hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers'Cornensation Insurance,.or HEATING-VENTILATING-AOR COfl DOTIONO`NG
a ce ia: ,o "ther.of'. ,c.3£tp L ;
Po.cy o. pan
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COiU d V OF LOS ANGELES
E] Certified copy is hereby furnished. �� �VO�®I��A�®�A����
Certified copy is filed with the county building inspection. BUILDING
FOR APPLI.CANT TO FILL IN:
department. ADDRESS
Date Applicant (PRINT.OR TYPE ONLY)
0111' LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEENEAREST
a�+� ��✓ " "'
COMPENSATION INSURANCE d
(This section need not be completed if the work involved ABSORPTION UNIT, BTU CROSS ST. O
by the permit is for one hundred dollars ($100) or less.) DISTRICT NO, PR SE v V
I certify that in the performance of the work for which this Alfl HANDLING UNIT,CFM d/
permit is issued, I shall not employ any person in any manner O
so as to become subject to the Workers' Compensation Laws. BOILER,BTU '�� U
P ,rt,�f ,�.y APPROVALS DATE INS"CTOR'SSIGNAIJRE
Date Applicant ( COMPRESSOR, BTU J `CJ ROUGH a
- 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 P
VALIDATION
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU ! V T-t;,Y_� y� y�_�
LICENSED CONTRACTORS pECLARATION FLOOR; BTU
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
ness and Professions Code, and my license is in full force and
effect. _
License Number -1- 3'T Lie.Class40,0
+ J
Contractor pv Date
0 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- PERMIT ISSUING SEE fG7
iness and Professions Code).
Lie.or Reg.No. Date TQYAL I=CE ��
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm .that I am exempt from- the Contractor's NAME
License Law for the following reason (Section :7031.5, Busi- z 0,83 0 A
ness and Professions Code): . ADDRESS
I, as owner of the property, will do the work and•the, CITY TEL. NO: # o so•o e o 8
structure is not intended or offered for sale (Section
7044,Business and Professions Code). 4 2 -:-.27,0 0
❑ OWNER (� /�
I, as owner of the property, am exclusively contracting �+s
With -licensed contractors to construct, the project MAIL / °-o f° 2 7.0.0'5
f22 z /i',r� j:
(Section 7044,Business anfl Professions.Code). ADDRESS� �
�' 6A�1TI/,� TE L.NO�_�,. 0'8.2,01 81
CITY
CONSTRUCTION LENllING AGENCY
I hereby affirm that there is a construction lending agency CONTRACTOR
for the performance of the work for which this permit is t��n/ a i�� �/0"
issued(Sec. 3097,Civ.C.).
Lender's Name ADDRESS eo e/,/%o/Z%.
Lender's Address CITY s iEL.NOS
I certify that I have read this application and state that the STATE �+� L- LIC.
above information is correct.I agree to comply with all County LICENSE NO. � CLASS
ordinances and State laws regulating Heating, Ventilating and
Air Conditioning, and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
Coll ty to enter upon the above-mentioned property for
ills eetic n purposes. f�
Signature of Permittee v Date