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HomeMy Public PortalAbout6116 HART AVE_Mechanical__ �QRINRS'COMPENSATION,DECLARAT rJN CEA 8 8(2.80) A If-- If� LAC AT�O II V FOR IJ—E R M ff - I'hP- by affirm that I have a' certificate of-consent to self aIu. (*-certrLcateof-Workers'Compensation4rsurance,o'r — �AY1111Cv-�IEWYIL ITIS rL�1163 C®�®1�1��1R1Q'v - ertifi� co th;�er0e f(Sec. 3800,h�h�C.) r uic�Bfo �` � Company—"try/vy r'Certifidd copy is hereby furnished,( COUNTY OF LOS ANGELES BUILDING AND SAFETY- Certified copy is filed with the county building in-p-c ion FOR APPLICANT TO FILL IN ' g BUILDING / FC . � y �'/!'4�� (PRINT OR TYPE ONLY) ' ADDRESS l/5/ Date 0>.Applicant / LOCALITY CERTIFICATE`OFEXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR-EQUIPMENT FEE • ' fC COMPENSATION 4NSURANCE NEAREST (This section need not,be completed if the work involved -ABSORPTION UNIT, BTU GROSS ST;" 0 by.the permit is for one. hundred dollars ($100).'or less,) DISTRICT No.•- paocesseD av U AfR HANDLING UNIT CFM I certify that in tlie,performance of the work for which this f}r,. permit is issued, 1 shall not em ploy any'person in any manner a I{J�)� ///{� O so as to become,subject to the WorkersCompensation Laws. Bbd LER, BTU APPROVALS DATE �1NSPEC R'S GNATURE •;W'- Date ' Applicant COMPRESSOR,BTU. d ROUGH NOTICE TO APPLICANT: If,after making this Certificate.of VENTILATION SYSTEM' - Exeinption, you, should become subject to_the Workers' FINAL Compensation provisions. of the Labor Code,you must forth- with comply with such provisions or this permit shall be EV APORATLV•ECOOLER VA L1 ION deemed revoked. ✓r FURNACE:-. FAU o�I AVITY / 1 LICENSED CONTRACTORS DECLARATION FLOOR: - BTU 7751_OAC/ !L% 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. -7 License Number y637J-Lie.Class Contractor' 0N/J6!2. .. Date • Y - • - V am exempt from.the licensing requirements as I am a licensed architect. or a registered professional engineer. Plan GheCk fee 25%Of above. acting in my professional'capacity,(Section 1051,'Bus- PERMIT-'ISS"UING FEE $ ' ness:and Professions Code): ' ',. ` o 0 0 0,0 8' Lic.or Reg.No Date TOTAL FEE HOME OWNER-BUILDER DECLAKATION © o 0 2 Q'5 0 LE: PLAN CH_ECK.APPL-ICANT Ihereby affirm that•I .a'rn -exempt from--the. Contractor's NAME '622(3 j:8 8 License Law for.the following reasonr(Section 7031..5; Busi- ness and'Professions Code): 'ADDRESS "l, as owner, of the property, will do the work and the structure.is not-intended or offered for sale (Section' CITY TEL. NO: 7044,Business and Professions Code)... # OWNER` �,q I, as owner'of the property, am exclusively contracting 41 with licensed contractors to construct the project MAIL R` (5ection'7044, Business and Professions Code). ADDRESS'z/ CONSTRUCTION LENDING AGENCY Cl'TY�Pnje TEL NO �s. I hereby affirm that there is a construction lending agency -for .the performance of the work for which this permit is . CONTRACTOR �8 issued(Sec. 3097,Civ.C.). p Lender's Name ADDRESS Lender's Address CITY Tpr `� `'� ;fEL.NO'.- 19 Q� /S7 d certify that I have read this application and state that the STATE r LIC. v A above information is correct.I agree to comply with all County LICENSE NO. /.S :7 CLASS��y�p 0—-3 ordinances and, State laws-regulating Heating, Ventilating and Air Conditioning, and.hereby authorize representatives of this SEE REVERSE FOR E_XPLANATORY'LANGUAGE County to enter upon the above ioned property for insp i n purposes. S.gnatur of Permittee Date x(1 6