HomeMy Public PortalAbout8814 GARIBALDI AVE_Mechanical__ _ ORICERS'COMPENSATION DECLARATION CEA3818(2-80) APPLICATION FOR k R M ff
I heroby jNnd that I have d cer"cU&-of consent to self I
ibsure, or a.certificate 61 Workers'Compensation Insurance,or - H-EA74NG-VENTILATING-AIR CONDITIONING ILj'
a Fortified copy t erdof(Sec. 3800 b,C.) '
Policy N. Q M Company COUNTY OF LOS ANGE S �j AND SAFETY
Certified copy is.hereby fun' lshed. . y BUILDING A
Certlfled copy is filed with county bufiding Inspection
de o t., �/ FOR APPLICANT.TO FILL IN BUILDING �. •'
&n. 4 1 •"/1 ��� (PRINT OR TYPE ONLY) ADDRESS
Date ppllcant _L
LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE'
QCh
COMPENSATION INSURANCE NEAREST
ho section need not be completed If the wABSORPTION UNIT, BTU
work involved CROSS ST
by
--
by the pertttlt is for one hVdred.doflm ($100) or leas.) nlsrRlcT no. PR r (�
I certify that In the performance of the work for which this AIR HANDLING UNIT CFM r '
Rl
permit Winuo, I shill not employ any person1ft any m
w annerIrA
as to become subject Worker'bject to the Work ' Corhpensation I-Awl; BOILER BTU
- APPROVALS DATE INSPFGTORl �.
LU
Date_ Applicant w ( COMPRESSOR",BTU-—
OO a 03
- ROUGH v
NOTICE TO APPLICANT: If, after making thisCertificate of VENTILATION SYSTEM FINAL 3� Z
Exemption, you should become subject to the Worker'
Compensation provisions of the Labor Code-, y6u must forth-'
with comply with such prevision] or this permit shall be EVAPORATIVE COOLER VALIDATIQN
deemed revoked. FU RN ACF; FA RAVITY
LICENSED CONTRAC•CORS DECLARATION FLOOR:� BTU
I hereby affirm that 1 em-llcensed'under provisions of Chapter HEATER; SUSPENDED UNIT /
4 (co'mmencmg with Section'1000) of Dhislon 3 of.tha Busi- _ WALL. �C
nets and Professions Code, and my license is in fulljorce and.'
effect.
License NirrtkberLlc.Class
Contractor Data ;
,I am exempt: ftom the licensing 3rogPtremants as'I am a -
licensed architect -or a registered professional enainear Plan check fee 26%-of above.
acina In my professional capacity (Section 7051, Bus- r
Incas and Professions Code). PERMIT ISSUING FEE $ Q�
LIc.or Reg.No. Date TOTAL FEE _
+ HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that j'am exempt from- the Contractor's NAME
License Law for the-following roon (Section 7031..5, [3usj-
ns
nen and Professions Cede): ADDRESS $
1, as owner of the property,'will db tha wotk and the ^
structure Is not intended or offered for sale (Section CIT TEL. NO.'
7044, Bustnew and Professions Code).' .. '
OWNER
I, as off�{ner of the P1oPertYa
,.am exclu;ive}y contcting ,
Nvith Ilce Z contractor ns
to- construct the project MAIL — �'S"3 2-5"'A
(Sectidn'7044, Business and Profesa}oru Code).. AD DA ESS
' 4 CITY � - - ,#'o,o'}• 0
CONSTRUCTION LENDING AGENCY TEL. NO.
I hereby affirm that there is a construction lend) enc) 2
for the performance of the work for which this permit b CONTRACTOR .00 37 �10
Issued � c. 3097,CtV.C.).. io .0 - 3 7,Q 6
Lender s.Name -ADDRESS
Lender's Address CITY�� TEL.•NO.
I certify that I have read this application and state that'the STATE LIC.
above Information Is correct.I agree to comply with all County CLASS
ordlnancei and State laws regulating Heating,Ventilating and
Air Conditioning, and heteby authorize'repreeentatfves of this. SEE REVERSE FOR EXPle-�-NATORY I ANQUAGE_
County to enter upon the.above-mentioned property for_
call n our
S nature o'Parmittea 6ate --