HomeMy Public PortalAbout6117 ENCINITA AVE_Mechanical__ WORKr RS'COMPLNSATION DECLARATION 76A364C
I hereby affirm that I have a' certificate of consent-to self.- CE-818 (2-80) APPLICATION FOR PERMIT
insure, or a certificate of Workers'Compensation Insurance,or HEATING-V ENTILATING-Al R CONDITIONING
a certified copy thereof(Sec. 3800, Lab.C.)
PolicyCompany
'Certified copy i5 hereby furnished. COUNTY OF LOS ANGEL FfS BUILDING AND SAFETY
- '�/ � / // A/ •��y
Certified copy is filed with the county building infpeetion FOR APPLICANT TO FILL IN BUILDING
department. /N
Date - Applicant (PRINT OR TYPE ONLY) -
LOCALITI' G/�
CERTIFICATE OF EXEMPTION FROM WORKERS* NO. TYPE OF APPLIANCE OR EQUIPMENT FEE ✓�/
COMPENSATION INSURANCE - NEAREST
(This section need not be completed i( the work involved ABSORPTION UNIT, BTU— CROSS ST. ,[J 4-
qpO
by the permit is for One hundred dollars (SILO) Or less.) • DISTRICT NO. PROCESSFDBY t..)
1 certify that in the ll not mango of the person
in which this AIR HANDLING UNIT,CFM 3/0� 0
cr
permit is issuetl. I shall not employ any person�in any manner ,
so as to become subject to the Workers' Compensation Laws. BOILER, BTU
,,// ''// APPROVALS DATE INSPECTOR'S SIGNATURE L)
)[Date T"�'p�'Appllcant�jC_ CO MP RE SSO R,.BTU 13.
ROUGH b �3� �--�- U)
Exemption, you should become suhject to the Workers' FINAL
NOTICE TO APPLICANT: It, after making this Certificate of VENTILATION SYSTEM - Z
I
Compensation'provisions of the Labor Code, you must forth- _ EVAPORATIVE COOLEg' VALIDATION
with comply with such, provisions or this permit shall be !/
deemed revoked. / FURNACE: . FAU_ GRAVITY_ ,{1
LICENSED CONTRACTORS DECLAR ATION J FLOOR:— BTU—/_a Q�_a-Oo
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 m.y license is in full force and -
effect.
License Number Lie.Class
ContractorT_ Date .
1 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-. r
loess and Professions Code). PERMIT ISSUING FEE $ 7
Lie.or Reg.No. - TOTAL FEE (,
Date-
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT ,
I hereby affirm that f am exempt from- the Contractor's _ NAME
Licens" Law for the followdng reason (Section 7031.5,. Rbsi-
nest ad Professions Coda): ADDRESS
J I, as owner of the property, will do the,work and the - TEL. NO.
structure is not intended or offered for sale (Section CITY 4 6,6..4 R
7044, Business and Professions Code).
OWNER
I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project MAIL
(Section 7044, Business and Professions Code). ADDRESS fQalC_3_(y iC..✓!✓�E i1.'T_- Zl^�- 1 7.0.0.
CITY - TEL.NO. pp •y I
CONSTRUCTIONALENDING ction len /. ZO_-3i_7,3 °.• °11 7:0
I hereby affirm that there is a construction lending agency CONTRACTOR '
for the performance of the work for which this permit is 0 Q 0.7_8 1
issued (Sec.3097.Civ.C.). .
Lender's Name ADDRESS
Lender's Address CITY L. NO.
1 certify that I have read this application and state that the STATE LIC.
above informs,^ is correct. 1 agree to comply with all County LICENSE NO. CLASS
ordir-_,.. •o" SOt laws regular tnR Heating, Ventilating and
A Co .d it'or and hereby authorize represematives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
r outy r, ' .':r up/�/rf�the above-men[ioner' p//r'o�pen//�y//for
qectir
t �
S na.ur Permittee Date '