HomeMy Public PortalAbout8761 GARIBALDI AVE_Mechanical__ APPLICATION
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WORKERS'COMPENSATION DECLARATION CEA 818 (2 80) F 4..ICP 1 �� V �O �� R1Y �� /
I hereby affirm that I have S certificate of consent to self
iruure, or a cerdficite of Workers'Compensation Insurance,or HEATING-VENTILATING-AIR CONDITIONING
e certlfled copy thereof(Sec. 3800, Lab.C.)n 'l i LJ
F Pollcy NoZompany�•�V�S 1Lldle
❑ Certified copy.is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with the county building Inspe n /
de�tm�ent�t/ FOR APPLICANT TO FILL IN BUILDING
Date_.�L ( AppllcEnt (PRINT ORTYPfi ONLY)
'
CERTIF TATE OF EXEMPTION FROM WORKERS' - NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY O/Qf•
COMPENSATTON INSURANCE NEAREST
(This section need pot be completed if the Work {noted ABSORPTION UNIT, BTU CROSS ST.
by the. permit is 'dor one hundred doUsi4 ($100) or fess) DtsTRICT ria. PRocE66SeD BY
I Certify that in the performance.of the work foe which this AIR HANDLIN UNIT CFM �!
permit is Issued, I shill not employ any person In any manner ✓/5
so as to become subject to the Workers' Compensation La\W.. I BOILER BTU . 0
TOR3aIort�7VBE
APPROVALS DATE. INSPEC
Date Appltrant COMPRESSOR BTU O ROUGH a
NOTICE TO.GPPLICANT: If, aftier making this Cortificate of05
VENTILATION SYSTEM FINAL 05
Exemption, you should-.become subject to the Workers' _
Compensation provisloru of the Labor Code, you must forth- EVPtP�RATIVE COOLER VALIDATION
with comply with such probitloru' or this permit shall be .
deemed revoked. F FURNACE: FAU V
LICENSED CONTRAC`fOP.SDECLARATION FLOOR• BTU
I.hereby affirm that 1 am licensed under provisions of Chapter HEAT(ER:. SUSPENDED UNIT
9 (commencing with Section 7000) of Division 3 of the Bbsi ' a WALL_ t
nets and Proeas
florls Code, end my license is to full force and
,effect. C C
3Y rS 20 -
License Number 0 3 7 Llc.Class
n- •-7�C,p___y -
Contractpr f ' &!!/ 0 - die- Date 75
❑ I am,exempt from the licen�ing requirements as l am a
licensed archttect or a r;ostdred profemionEl engineer ` . Plan check The 25%of sbrn+e.
acting In my professional capacity (Sectlon.7051, Bus-
iness and Professions Code).. PERMIT ISSUING FEE
Lic.or'Re'g.No. Date TOTAL FEE
`
HOMEOW DECLARATION PLAN CHECK APPLICANT
I h"by affirm that I' am exempt frr,m- the Contraetor'f NAME
(J Llcer)se Law for the fallowing reason (Section 7031.5, Bull- 3 3 E 2 A
v nets and Pro feArdons Code): ADDRESS
❑ 1, as owner of the property, wnl do the wbrk end thea,o}o • 0'Q.8
structure Is riot intended or offered for sale (Section CITY TEL. NO. r
7044, Buaineu and Profeaatons Code. OWNER .,2 ole 3 Q b p
❑ 1,as owner of'the propert},, am exclusively contracting Z"eo'o 0 7j Q 6 p
with licensed. contractors to construct the project MAIL r
(Section 7044, Bustness end Professions Code). ADDRESSl] $ p 9_8-4
CONSTRUCTION LENDING AGENCY CITY � � TEL.NO. _
I hereby affirm that there Is a construction lending agency,
for the performance of the work for which this permit is CONTRACTORJ �•
Issued(Sec.3097,Civ.C.). `
Lender's Name ADDRESS Al
F
Under' Address CITY TEL. NO.//// _ ;Z
1 certify that I have read this application and state that the STATE , LIC. TY
above information Is czrrect.I agree to comply with all County C E N 0 CLASS
ordinances and State laws regulating Heating, Ventilating.8nd
Air:Conditioning, and hereby euthortse representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
County to enter upon theabove-mentioned property for
fns on pur ]
gnatu of Permittee Date