HomeMy Public PortalAbout5646 GRACEWOOD AVE_Mechanical__ �RKE-2S'COMPENSATION DECLARATION CEAB18Iseo) APP,L1CATIOfV FOR PERMIT
I hereby affirm that I have a certificate of consent to self _
Insure, or a certificate of Workers'Compensation [nsuraitce,or HEATING-VENTILATING-AIR CONDITIONING
a certified copy thereof(Sec. 3800,Lab. C.)
Policy No. Cohtpany
�'-ertlfled copy 4 hereby furnished.
COUNTY OF LOS ANGELES BUILDING AND SAFETY
•Certlf}ed copy is flied with the county bufldlrig inspectlon FOR APPLICANT TO FILL IN BUILDING
department. 6
Date Applicant (PRINT OR TYPE ONLY) ADDRESS
� CERTIFTtrATE OF EXEMPTION FROM WORKERS'
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY
COMPENSATION INSURANCE NEAREST
(This sec n need not be completed if the work Invoh+ed ABSORPTION UNIT, BTU CROSS ST. U�
by the.permit to ,fod,one hundred dollars ($100) or lees.) DISTR1CT NO. PK By 8
I certify that In the performance of the work for which this AIR HANDLING,UNIT CFM /J D cc
permit is Issued, I shall not employ any-person In any manner (/o
sp aa.to b co a subject to the CoMpensatldn laws. BOIL R BTU O
APPROVALS DATE N-
U.
ifiP CCDRT al TURK
Datpplicant COMPRESSOR BTU ROUGH
NOTI APPLICANT: If, ■ ter akin thls Certlflcate of VENTILATION SYSTEM FINAL
Exemption, you should become subject to-"-the Workers'
Corepens#tldn provisions of the Labor Code, ydu muit fotth- . EVAPORATIVE COOLE �IALID ION
with comply with such provfslons or this permit s1i"'be
deemed revoked.
LICENSED CONTRACTORS DECLARATION FURNACE:FLOOR: BTUtoo
—BTQ GP AVITY
I hereby affirm that I am licensed under provisions of Chapter HEATER: SUSPENDED UNIT
9 (commencing with Section 7000) of Dlvislon 3 of the Busl. WALL
ness and Professions Code, and my Ilcenae is In full force and
effect.
License Number Lie.Glass
Contractor Date
I am exempt from the licensing requirements ■s I em a
Ilcensed architect or a registered professional engineer Plan (heck fee 25% of above.
acting In my -protesslonal.capacity (Stiction 7051, Bus-
iness and Professions Code).' PERMIT ISSUING FEE$ Q
Lie.
R4 7.6A
or Red.No. Date NOTAL FEE � ..
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT # a a a 8
I hereby afMm that I am exempt from- the Contractor'f - NAME 1••,• 2 Q J`O
License La .for the following reason (Section 7031.1,.Busl- n
na"an ofesslom Code): ADDRESS i .a e 2 Q J5 O 6
as owner of the property; will do the work and the
structurp L not .Intended or offered'for sale (9ectlon CITY TEL. NO. O E.0286
r 7044, Buslneas and Profeaslons Code).
❑ OWNER s
I, as owner of the property, am ezcluslvely,contracting
with. licensed- contractors to construct the project MAIL
{Sectbn 7044,Business and Profeaatons Code). ADDRESS
CONSTRUCTION LENDING AGENCY CITY TEL.NO.
Ihereby_effirrrt that there Is a conatructlon lending agenc99
for the performanco- of the work fbr which chis permit In CONTRACTOR -
issued (,Sec. 9097,
r Lenders Name ADDRESS
Lender's Adelress CITY f EL.NO. -.
1 certify that I have read this application and state that theSTATE LIC,
above infor-Mtlon is correct.I agree to comply with all t~ounty I LICENSE-N_ . CLASS _
ordinances and State laws regulating Heating, Ventilating and
Air Conditioning, and hereby authorize representativer pf this SEE REVERSE FOR EXPLANATORY-LANGUAGE
County to enter upon the above-mentlone-d property for
u poses.
Z2 d,c-b
C �v f Permittee D.1,