HomeMy Public PortalAbout5942 ENCINITA AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION �76A364C -
},, CE -818 (2-80) APPLICATION FOR (PERMIT
I I:ereby e..irm that I have a certificate of consent to self
insure, or a certificate of Workers'Compensation Insurance,or HEATING-VENTILATING-AIR CONDITIONING
a certified copy thereof(Sec.3800,Lab.C.).
Policy No. � /C�Ampan
V Certified copyhereuy�u Wished �~�OP�/e�fTr COUNTY OF LOS ANGELES BUILDING AND SAFETY
I < Certified copy is filed with the county building i spectlon BUILDING
FOR APPLICANT TO FILL IN
d oartme^/t. D
Date -"Lf2Applicant- -1— -til (PRINT OR TYPE ONLY) ADDRESS r/
i^ 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. CLQ
by the permit is for one hundred dollars (5100) or (CSS.) DISTRICT NO. PROCESSE By .(�
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM �^ cc
permit is issued, 1 shall not employ anyperson in any manner O
so as to become subject to the Workers' Compensation Laws.. BOILER, BTU U
APPROVALS DATE INSPECTOR'S SIGNATURE
Data Applicant a CL
COMPRESSOR,R,BTU ROUGH i�� ,_- U)
NOTICE TO APPLICANT: after making this Certificate of - NON SYSTEM p Z
Exemption, you should become
VENTILATION subject to the Workers' FINAL
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER with comply with such provisions or this permit shall be )(A' IDATIO
deemed revoked. FURNACE: FAU_ GRAVITY_ -
LICENSEDCONTRACTORS'DECLARATION; FLOOR: BTU Ifo /
heieby affirm that I am licensed under provisions of Chapter HEATER:' RENDEO UNIT OY
9 (commencing with Section 7000)of Division 3 of the Busi- WALL , _7S400 /p
(ness
and Professions Code, and my license is in full force and
effect.
License Number ZZy l c, 7 Lic.Class
Contractor 6991'� I C� Date
�E] 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- '
iness and Professions Code). PERMIT ISSUING FEE $ -
Lic.or Reg.No. Date TOTAL FEE !�
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-
ness and Professions Code): ADDRESS
1, as owner of the property, will do the work and the CITY G TEL. NO. , '7
structure is not intended or offered for sale (Section/
7044. Business and Professions Code). - �� � r
❑ OWNER .r/L�p,(/ �,1'Ob9A
I, as owner of the property, am exclusively contracting /
with licensed contractors to construct the project MAIL
(Section 7044, Business and Professions Code). ADDRESS 6
CONSTRUCTION LENDING AGENCY CITY TEL.NO. .2 iX • e 1 7,O O ?.
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is CONTRACTOR I /L�� �s �a e e ) 7. 00'
issued (Sec.3097.Civ.C.). (�/
Lender's Name ADDRESS `/ 4 ��,0��1�G' O 9.0,8'—8 )
Lender's Address CITY ��L ` TEL.NO.77/ h7
�
I certify that l have read this application and slate that the STATE Z U .LIG /
above information is correct. I agree to comply with all County LICENSE NO. J� 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 up�qq the above-mentioned property for
ins,ell Ion purposes.
Signature of ' Witte, Date '