HomeMy Public PortalAbout5210 ENCINITA AVE_Mechanical__ �. 'rW(3R'#c*S'COMPENSATION DECLARATION 764364C P(�j gg Npe 0�q,R(� ((��//��
CE -818 (2-80) �Ir �����',0 .�®ttlL. If�t ���Y�U �� ,
I hereby affirm that I have a certificate of consent to self '
insure, or a certificate of Workers'Compensation Insurance,or , -HEATING-VENT.ILATIRIG-AIR CONDITIONING
a certified copy thereof(Sec 3800, Lab C.) + ;
Policy No Company
COURT•Y OF-LOS ANGELES BUILD=ING AND SAFETY
Certified copy is hereby furnished. u
• Certified copy>s filed with the county building inspection _ BUILDING
department. FOR APPLICANT TO FILL IN ` ADDRESS i,�
ate' -Applicant" ,(PRINT"OR,TYPE'ONLY.)„ F,� _
- LOCALITY "Sr / �/ [ G
CERTIFICATE OF EXEMPTION FROM WORKERS', ' NO TYPE OF APPLIANCE OR EQUIPMENT FEE r / ;
COMPENSATION INSURANCE NEAREST`
(This section need,not'be completed if the work involved, _ ABSORPTION UNIT;BTU CROSS ST a '
by the-permit is for one hundred dollars ($100),or less.) ; "DISTRICT NO Pr, cE� Eoev U
I certify that in the performance'of the'work for,which'this . AIR,HANDLING UNITy,C,FMt cc _
permit.is�issued, I shall not employ,any person in any manner 0
so as to.become subject tb the or ers' Comperisati ri Laws. BOILER,-BTU
{{ /) APPROVALS DATE INS C JR'SSIGNATURE IU '
`Dates r Applicant_ _ COMPRESSOR,BTU d �� �" f -ROUGH / _ N -
NOTICE TO APPLICANT: If, after,making this rtificate of, ' '. - . ! %+ � Z,
r VENTILATION SYSTEM, • FINAL m �I
Exemption; you should become subject to the Workers' —
Compensafion•provisions of the Labbr Code you•must-forth--
with'comply'>with,such:p�ovisions` or fbis ,permit shall be EVAPORATIVE VALIDA, ION
,deemed revoked FURNACE •�•FAU -GRAVITY
LICENSED CONT•R,iCTORS DECLARATION FLOOR BTU
I hereby'affirm that I am licensed under provisions of Chapter HEATER. 'SUSPENDED•,• UNIT _v
9 (commencing with Section 7000) of Division 3 of the Busi- —WALL'--=
ness and Professionsase,ts,m
,Code,' nd my -full,force and?
effebt._.= r - .,.. ��..���� ;@,.l 3 4,b A
License Number_ Lic Classy # • • ono • 8
CLi MA- a CoklTTbt3L _1��5 S� `O • 2 Q 5
Contractor Date
0 _... _ . ... 2.0,50
I'am exempt,from the m
licensing requireents as I am a
licensed architect-or a registered professional'engineer Plan check fee 25%of above. c Q 1'.1 5'=8 5
acting in my professional capacity (Section 705.1, Bus
iness and Professions Codej.', PERMIT ISSUING FEES$
-Lie.-or Reg No. Date TOTAL FEE
HOME OWNER-BUILDER DECLARATION PL/ASN CHECK APPLICANT
I 'liere'by affirm that I am' exempt from- the' Contracfor's NAME C
License Law for the.following reason (Sectio_n 7031 5; Busr-,
ness and Professions Code) ADDRESS 15"(j ���� �_� 'JS
4=•
-F� 1, as gwrier, of the property,'-will do the work grid the " CITYY -TEL. NO � CF
Structure'is not intended or offered for sale (Section
7044, Business and Professions Code).
OWNER
ElI, as owner 'of the property, am exclusively contracting
with licensed contractors _to construct the"' project , MAIL _
(Section 7044, Business and Professroms Code). ADDRESS' _ T'- P'
TEL.NO
-CONSTRUCTION LENDING•AGENCY CITY
I.-hereby affirm that'there is a construction lending agency
for,the performance of the work for which-this'permit is CONTRACTOR
issued(Sec'. 9097,Civ.C.). - •-
Lender's'Name ADDRESS
Lender's Address ! CITY _TEL,NO: ,
I certify that I have read this application and state that the STATE LIC.
abbve information is correct.1 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
"Capi��cu
' enter upon the above-mentioned ,property for
uur uses ., 4 a , . •_ _; - _ '
Signature of Permittee D e