HomeMy Public PortalAbout5519 HALLOWELL AVE_Mechanical__ WORKERS' COMPENSATION DECLARATION APPLICATION FOR PERMIT
,I�aer�by,�tfirmthat I have a certificate of consent to self
+;isure,l or a certificate of Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
or a i0tified copy thereof (Sec. 3800, Lab. C.) CEA3618(REV. 10/81)
ti�9y�o4797'02-Oampany Fremont
Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
0 Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING
tion department. (PRINT OR TYPE ONLY) ADDRESS 5519 North Ha 1 V
Date 4-16-91 Applicant AAA C'ond Al r LOCALITY mem 'le Cit
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS/'- NEAREST ��1�
COMPENSATION INSURANCE CROSS ST. Arden Driv
(This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO. PROCESSED BY
the permit is for one hundred dollars($100)or less.)
AIR HANDLING UNIT, CFM
I certify that in the performance of the work for which this � �.
permit is issued, 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 Applicant COMPRESSOR, BTU 48 , 000 ROUGH
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINALd*u�
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDA ION
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU XX GRAVITY
LICENSED CONTRACTORS DECLARATION ' FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED—UNIT—
(commencing
USPENDED UNIT(commencing with Section 7000) of Division 3 of the Business HEATER: WALL
and Professions Code,and my license is in full force and effect.
License Number 293529 Lic. Class C 2 O poll. O
U
Contractor AAA Cond Aincite 9-30-92 21 O'•
❑ I am exempt under Sec.
Plan check fee
B.BP.C. for this reason
Date:
PERMIT ISSUING FEE $ z
'
Signature TOTAL FEE ti
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT 3 I =T
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and NAME
Professions Code): a q s
I, as owner of the property, or my employees with ADDRESS
El "
wages as their sole compensation,will do the work and E' I `
the structure is not intended or offered for sale(Section
CITY TEL. NO. ��"L°�� '� 6 ���
y
Vt. fr'Ul f
7044, Business and Professions Code).
❑ OWNER r_'
I, as owner of the property, am exclusively contracting Bruno
with licensed contractors to construct the project (Sec- MAIL =
tion 7044, Business and Professions Code). ADDRESS 5519 Nnrth
CONSTRUCTION LENDING AGENCY CITY rn TEL. NO p
mem le City 444-9.,67 k i _ �
I hereby affirm that there is a construction lending agency for f_t¢a � � ITt c 171
the performance of the work for which this permit is issued CONTRACTOR
(Sec. 3097, Civ. C.). . iAA C.onditione.d Air _-__ AM
Lender's Name ADDRESS 10160 Valley- Blvd.
Lender's Address CITY :E1 14ont-e TEL. NO. 579-160
I certifythat I have read this application and state that the STATE LIC.
pp LICENSE NO. 2 9 3 5 2 9 CLASS' C 2 O
above information is correct. I agree to comply with all County
ordinances and State laws relating to building construction,
and hereby thonzer re ntahves of this County to enter
upon the a v t' n r errty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
David Cross
Signature of Applicant or Agent Date