HomeMy Public PortalAbout5472 ENCINITA AVE_Mechanical__ < :'"+QRS'COMPENSATION DECLARATION CEA3818C(2-BO) Q p p� C A it S O N FOR p E fR W T
;by affirm*that I have a' certificate of.consent to self
or a certificate of Workers'Compensation Insurance,or' HEATING-VENTILATING-AIR C0 DITIONINCv
rtift'ed c)o�py.�,,tf--,,:ereeof(Sec. :3800, Lab.C.)�
Policy No..��,7_LL�kompany
Certified copy is hereby furnished.
COUNTY OF LOS ANGELES BUILDING ARID SAFETY
Certified copy is filed with the county building insp .tion FOR APPLICANT TO FILL IN BUILDING
f�epart ent. e--->Dat�+ � Applicant � M lP'tit�if (PRINT OR TYPE ONLY) ADDRESS
LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT, FEE
COMPENSATION INSURANCE NEAREST }
(This section need not be completed if the work involved ABSORPTION UNIT,,BTU CROSS ST. 1 t.p wL`\ O
by the permit is for one hundred dollars (5100) or less.) DISTRICT NO. PR ESSED.BY U
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM �../..►� Aa4�1
permit is issued, I shall not employ any person in any manner U 0
so as to become subject to the Workers' Compensation Laws. BOILER, BTU I—
�, APPROVALS DATE INSPECTOR'S SIGNATURE U
t
Date Applicant COMPRESSOR,BTU b ROUGH _ y
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM �/ Z
Exemption, you should become subject to the Workers' FINAL
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION
with comply with such provisions or this permit shall be
deemed revoked.
FURNACE: FAU
LICENSED CONTRACTORS DECLARATION ' 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 Lic.Class
ContractorR" ( CaE1N Date 4_Jeba
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-
mess and Professions Code). PERMIT ISSUING FEE $
Lic.or Reg.No. Date TOTAL FEE b D
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- 'i• Z .
E! as
' ness and Professions Code): ADDRESS C.
1, as owner of the property, will do the work and the X37.1 `I_=v=_{
structure is not intended or offered for sale (Section CITY TEL. NO. <
7044, Business and Professions Code). s '� . ^
D OWNER (���S��t:1 ��Af� f_f Ai n k�k
1, as owner of the property; am exclusively contracting I:,_ _��_ e � •�B
with licensed contractors to construct the project MAIL . � +
(Section 7044, Business and Professions Code). ADDRESS D g' W.. 94�- L, j
CONSTRUCTION LENDING AGENCY CITY TEL. NO.
CON.71TpA�1� �; T'�
I hereby affirm that there is a construction lending agency A All
for the performance of the work for which this permit is R a� Pfrt't r
issued (Sec. 3097,Civ. C.). i'I-,ti•.
Lender's Name ADDRESS t4� ?
Lender's Address CI,TYCCVNQ TEL. NO.r _wap
1 certify that I have read this application and state that the STATE -� LIC.
above information is correct.I agree to comply with all County LICENSE NO. C�j' oma. 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- entioned property for
intio pu oses.
Signature of Permittee kDate