HomeMy Public PortalAbout5341 ENCINITA AVE_Mechanical__ N'ORKERS'CUr.7i'c; :S.-:i,Lti 0,:U_AKATiON 76A364C o 0 0 0 0
I hereby affirm that I have a cer,ificaie of consent to;sPl CL-81,8 (2-80) Q�Q� Oo fN FOR p G3 0`�
insure, or a certificate c.WVo!l ers' Compensation Insufance,or -- G;IEA76NG-VENT ILAT9NG-90R CONDOTIONON(M
a certified copy thereof(Sec. 3800�"fj c..�CC' ) L.I
Policy No.
Certified copy is hereby furnished. COUNTY V®F LOS ANGELES BUILDING AND SAFETY
Certified copy is filed e✓ith the county bu" .g'.1s'ection ®R �aPPLOh1
�� T TO FILL IN BUILDING r t�
O.-paarrtment ADDRESS
DateQ 0LCF_1fA licant _ _ I (PRINT OR TYPE ONLY)
LOCALITY / r
CERTIFICATE OF EY,cUP 1001 cRCJA%I WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE V
CONIPENSATICN ,NSURANCE NEAREST
CROSS ST.
(This section need not be co- pi:�:eek - ^_°ie work 'involved II ABSORPTION UNIT, BTU C — t1
by the permit is `a_ mic .1L IC_C CC`-.tSs (S'-C3) Cr 6ess.) li DISTRICT NO. i PROCESSED BY O
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM
permit is issued, I shall not employ any person in any manner I L 0
so as to become subject 'Lo the 1Vorkers' Compensation Laws. BOILER, BTU
16 �� APPROVALS DATE_ I c OR's TURF w
Date Applicant / COMPRESSOR, BTU 1 ROUGH _ 0-
NOTICE TO APPLICANT: U, afier making this Certificate of VENTILATION SYSTEM FINAL / U)
Exemption, you should become subject to the Workers' I l
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOT-ER VALIDATION
with comply wit'n such provisions Or this permit shall be
deemed revoked. FURNACE: FAU_1y GRAVITY
LICENSED CONTRACTORS DtCLAR ATION I,
/ FLOOR: BT-6
I hereby affirm that I am ' tensed urde;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 NumberS_Qu,?/_i_, Lic. Class
Contractorf-t1✓/ j�G% Date,
I am exempi :.om u1e licensing requirements as i am a
-licensed architect o-. u registered professional engineer Plan Check fee 25%of above.
acting in my professicnai capacity (Section 7051, Bus-
iness and Professions Ccde). ! PlVRNiOT MUOfl10 FEE $
ir
Lie.or Reg.No. Date T07AL FEE
HOME OWNER-BUILDER DECLARATION I 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- I'
ness and Professions Code): _ I ADDRESS "3 8 a 2 A
1, as owner of the property, will do the work and the I CITY TEL. NO.
-
structure is not intended or offeid for sale (Section # 0 0 o o,o 8
7044, Business and Professions Code).
�
DI, as owner of the property, am exclusively contracting OWNER 661�C) e w ,1 I—Irls— 12.. -,30,.5.0
with licensed contractors to construct the project MAIL
(Section 7044, Business And Professions Code). ADDRESS 1.0..0 °,3 0.5 0
5.
I
CONSTRUCTIO*NT LENDING AGENCY CITY TEL.NO. O R 3 0—8 4
I hereby affirm that there is a construction lending agency
for the performance of the work
which this permit is CONTRACTOR �Gp �+�
issued(Sec. 3097,Civ.C.).
Lender's Name II ADDRESS7,96 /V` -
Lender's Addressvia //(/ TEL.NO.
I CITY j
I certify that I have read this application and state that the i STATE,/ LIC. �.aQ
above information is correct.I agree to comply with all County LICENSE_NO�0V �5 CLASS
ordinances and State laws regulating Heating, Ventilating and
Air Conditioning, and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
County to ente• u• m .he above-mentioned property for
insnect'on pulp ,e.
Signature of P .mitt, Date