HomeMy Public PortalAbout5566 HALLOWELL AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION ,i A 86 SC
CE (2-80) Ga p IP C °,T 0 O N FOR p E R MT
1 hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers'Compensation Insuran e,dr HEA70MG-V E(�y�j0L/,a�'ING-AOR �O rf��l'D579OGJ'o`H(M U
a cee, , ie�dj c�opGy�thereof(Sec.3800 `,ab.C. , !;
P,1/icy—IVr/.Jgk—Zompan. .(L —- -_ i
Certified copy is hereby furnished.
r COUNTY OF LOS ANGELES RUIL®ING AR9®Sb11FETV
(?}t� Certified copy is filed with the ;ounty building inspection FOR APPLICANT TO EI LL IN
BUILDING r �/�
` dela .mert. ADDRESS 20�I' ...���/// (PRINT OR TYPE ONLY)Date_/$_��.pplicant_ LOCALITY
'ER/T FICATE OF EXEMPTIN 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. Oa
by the permit is for one hundred dollars ($100) or less.) DISTRICT NO. PROCESSE 'V L)
I certify that in the performance of the work for•which this AIR HANDLING UNIT,CFM 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, BTUAPPROVALS DATE INSPECTOR'S NATURE W
Date Applicant COMPRESSOR, BTUs) /!�o ROUGH ) ` a
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL zJ
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION
with comply with such provisions or this permit shall be
deemed revoked.
- FURNACE:. FAU—�— GRAVITY �
LICENSED CONTRACTORS DECLARATION 1. FLOOR::—__._BTU_ _ �14D /
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- WALL
ness and Professions Code, and my license is in full force and
effect. oo�9 !'�
License Num
berG�� CJ_J_ Lie.Class—C-7---o—
Contractor
Contractor _ ?2m
_ Date _3.1��I am exempt the licensing re�uirem ,its as I am a
lic lsed archor a registered professional engineer Plan check fee 25%of above.
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code). PERMIT ISSUING EEE $
Lie.or Reg.No. Date TOTAL EEE ��
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby,affirm that 1 am exempt from- the Contractor's NAME
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): ADDRESS ,4 4 8,15 A
OI, as owner of the property, will do the work and the #,o'0'0 o-0 8
structure is not intended or offered for sale (Section CITY TEL. NO.
7044, Business and Professions Code). 1 0 030,5.0
OWNER
1, as owner of the property, am exclusively contracting
with licensed contractors to construct the project MAIL � •o !010 0 3 0,5 0 50
(Section 7044, Business and Professions Code). ADDRESS
CITY r TEL N ,41 `3_/ -)7 0 8 1 21-8.3
CONSTRUCTION LENDING AGENCY _ � _ `7_7_,,,J
I hereby affirm that there is a construction lending agency f
for the performance of the work for which this permit is CONTRACTOR
issued(Sec. 3097,Civ.C.). !�
Lender's Name ADDRESS ��yy
Lender's Address CITY �. TEL.NO.
I certifythat I have read this application and state that the pp STATE — LIC.
above information is correct.I agree to comply with all County LICENSE NO. _]3SS�9 CLASS C-Z n_
ordinances and State laws regulating Heating, Ventilating and ! I
Air Conditioning, and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
Countv enter upon the ab"ve-mentioned property for
in •-_ction purposes.
Signatt of Permittee .Date