HomeMy Public PortalAbout4814 FIESTA AVE_Mechanical__ s WORKERS'COMPENSATION DECLARATION CEA 8 8(2-80) Q p pUC °,T 0 O N FOR p E R M M
I he'reby affirm that I have a certificate of consent to self
insure,or a certificate of Workers'Compensation Insurance,or
a certified,cop}thereof(Sec. 3800,Lab.C'.)
Policy No. Company COUNTY OF LOS ANGELES BWLDNG AND SAFETY
Certified copy is hereby furnished.
Certified copy is filed with the county building inspection FOR �� f
department. EOAPPLICANT TO FILL ON ADDRESS 1
Date Applicant (PRINT OR TYPE ONLY) — - -
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. - CL
by the permit is for one hundred dollars ($100) or less.) DISTRICT NO. PRr SED aV V
I certify that in the performance of the work for which this AIR HANDLING-UNIT,CFM 0y cc
permit is issued, I shall'not employ any person in any manner _ O
so as to become subject to the Workers' Compensation Laws. BOILER, BTU -
APP*_ DATEIN
PECTO'.�'S SIGNATURE ()
Date ApplicantBTU-32;-0.10—el ROUGH N
COMPRESSOR,
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINALZ
Exemption, you should become subject to the Workers'Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLERIIIN
with comply with such provisions or this permit shall be
deemed revoked.
FURNACE: FA «GRAVITY
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-
ness and Professions Code, and my license is in full force and / fir- ,ry0
effect. p /��/� ]��t._l�V (f
License Number Z _ Lie.Class.e `ma��)tt
r
Contracto Date ^'r
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 USSUONG FEE $
Lie.or Reg.No. Date TOTAL (SEE .A-Ov
HOMEOWNER-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- J
ness and Professions Code): ADDRESS Y( a
I, as owner of the property, will do the work and the CITY TEL. NO.
;+:-r c;
structure is not intended or offered for sale (Section ,-_L€; _,e'•_f:
7044, Business and Professions Code).
OWNER171
_ 1Y`
I, as owner of the property, am exclusively contracting _ _ _.__ i1 �
with licensed contractors to construct the project MAIL 'J / T_;T � t
(Section 7044, Business and Professions Code). ADDRESS L�/ __ _ _
1 -00
CONSTRUCTION LENDING AGENCY CITY I TEL. NO CHECK $o;iJ
I hereby affirm that there is a construction lending agency _ / ' �E ;!
for, the performance of the work for which this permit is CONTRAC 'OR y'HHt9I)r
issued (Sec. 3097,Civ.C.). —-- — -
Lender's Name ADDRESS,J/�f - _ 0
Lender's Address CITY TEL. NO yj DOCK I"01IL•-: Ti/227 t
I certify that I have read this application and state that the STATE q` LIC• 090 s AN 10-4
above information is correct'. I agree to comply with all County LICENSE NO _/✓ d 6 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-mentioned property for
js�pe
r': purroses.� T.ire�f Per.nittee Late