HomeMy Public PortalAbout5015 DOREEN AVE_Mechanical__ I WORKERS'COMPENSATION DECLARATION CEA3 18(2.80) APPLICATION F O R PERMIT
1 hereby affirm that I have a certificate of consent to-self
{ insure,or a certificateolWorkers'C-..,P.rsationlnsurance,of HEATING-VENTILATING-AIR CONDITIONING
r rtified- P..".leerre(c/r(Sec: 00. . . '..) ��
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❑ Certified copy is hereby furnish, /— COUNTY OF LOS ANGELES �- / BUILDING AND SAFETY
✓rtified copy is filed with The county building inspection BUILDING�r / /{�
department. FOR APPLICANT TO FILL IN ADDRESSO?/ P/&—A/ a;�'�
Date ' Applicant (PRINT OR TYPE ONLY)
LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
COMPENSATION INSURANCE CNEAORSSEST
RST.
(This section need not be completed if the work involved ABSORPTION UNIT, BTU a
by the permit is for one hundred dollars ($100) or less.) DISTRICT NO. PRO _ By O
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM � P�
permit is issued, 1 shall not employ any person in any manner 0
so as to become subject to the Workers' Compensation Laws. BOILER, BTU - O
APPROVALS DATE 91�INSPECTOR'SS ATURE L)
Date Applicant COMPRESSOR, BTU ROUGH IL
W
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM N
Exemption, you should become subject to the Workers' FINAL Z
Compensation provisions or the Labor Code, youmust forth- EVAPORATIVE COOLER AL
per
With comply with such provisions or this permit shall he
deemed revoked. / FURNACE: FAU����G
LICENSED CONTRACTORS DECLARATION ` F.LOOR: BTU -
I herebv affirm that 1 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 .�r 'f�
License Number)) 733?Lic.Clasns_^C ZD
Contractor�4 1/�>� Date gum,014- pzwp 4 '
❑ 6 am exemptfrom 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). PERMIT ISSUING FEE $ Q Lie.or Reg.No, Date - TOTAL FEE
HOME OWNER-BUILDER DECLARATION- PLAN CHECK APPLICANT ,
I hereby affirm that 1 am exempt from- the Contractor's NAME
License law for the following reason (Section ]031.5, 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 p
7044, Business and Professions Code). - '25 4.7 A
❑ I, as owner of the property, am. exclusively contracting / d�'r/ C'/✓T�"e^ q
with licensed contractors to construct the project MAIL �—y� ,+ n •g-lu. S'-�� e 0:0.• 4 1
(Section 7044, Business and Professions Code). ADDRESS J '^'lS N ,
CONSTRUCTION LENDING AGENCY CITY '� ' TEL.NO. 2 e-s 1 Z 0 0•
1 hereby affirm that there is a construction lending agency ^ AN r.
for the performance of the work for which,this permit is CONTRACTOR 44�p�IA7 , �.CbF+s/IJG ' 'a 1'e's 17.0 0`6
issued (Sec.3097.Civ.C.). . / 1 -
Lender's Name ADDRESS /'70 ld lloe' 0/9/`•. 10.0'9.=8 Q
Lender's Address CITY n l w „ ��� TEL. NO.
I certify that 1 have read this upplication and state that the
STATE./fes-tJ'/n�'� LIC. i7
above information is correct.1 agree to comply with all County LICENSE NO. e,4ta� 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
hap r ^ pu�,••oseS. p
Ok
Signalmen Permtttee Date _