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HomeMy Public PortalAbout6117 HART AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION, CEA 818 (2-80) Q p(� �C ®N ®G3 p 0T I hereby affirm that I have a' certificate of consent to self irssure, or certificate of Workers'Compensation Insurance,or HEATING-V ENTILATING-AIR CONDITIONING ,, .a certified copy thereof(Sec. 3800.Lab C.) PolicyCompany'. — COUNTY-OF LOS ANGE ES ` BUILDING AND SAFETY Certified copy is hereby furnished.. - - Certified c;py is filed with the county building inspection BUILDING //{� FOR APPLICANT TO FILL IN �J " Da/ Applicant _ (PRINT OR TYPE ONLY) ADDRESS --} LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE COMPENSATION INSURANC> - NEAREST (This section need not be completed if the work involved ABSORPTION UNIT, BTU CROSS ST. �j�/� l/ d O O by the permit is for one hundred dollars ($100) or less.) - DISTRICT NO, PRO SS BY U I certify that in the performance of the'work-for which this— AIR HANDLING UNIT,CFM permit is issued, I shall not employ any person in any mann-r ((JJ so as to b•.:oos �,,jject to the Worke ' C mpensation Laws. BOILER, BTUWAP APPROVALS DATE INSP TOR'SSIGNATURE. lLJCL Dats" iicant_ _ COMPRESSOR, BTU J_ ©O ROUGH mea N NOTICEPLICANT. If, after making this Certificate of VENTILATION SYSTEM ' z Exemption, you should become subject to the Workers' FINAL '. Compensation provisions of the Labor.Code, you must forth OOLER L(/ ; ` Y/ALIDATION with comply with such provisions or this permit shall be' EVAPORATIVE C �� deemed revoked. FURNACE: FAU—. r I'e0 1-Y T/�.6 / LICENSED CONTRACTORS DECLARATION �- FLOOR: By /— I hereby affirm that I am licensed under provisions of Chapter HEATER:' SUSPENDED- UNIT 7G) 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. L License Numberg9_,. � ic.CI-s/_ y_0 el - -exempt a licensing requirements as,I am a licensed architect or a registered professional engineer Plan check fee 25%of above. acting in my professional capacity (Section 7051, Bus- iness and Professions Code). PERMIT ISSUING'FEE $ Ac.or Reg.No. Date TOTAL FE'E HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT I hereby affirm that I am exempt from- the Contractor's NAME License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): ADDRESS I, as owner of the property, will do the work and the a TEL. NO.structure is not intended or offered for sale {Section CITY 7044,Business and Professions Code): OWNER 2.3 O Jr 8 A ElI, as owner of the property, am exclusively contracting J _ with licensed contractors to construct the project MAIL i# 0.6;0 a 41 (Section.7044, Business and Professions Code). ADDRESS CONSTRUCTION LENDING AGENCY CITY TEL. "/ v �� P -:0,5z7,O O I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is CONTRACTOF _ o oIo 5 7 O O 5 issued(Sec. 3097,Civ.C.). — -- Lender's Name ADDRESS Lender's Address CITYV TEL. NC0�7� a I certify that I have read this application and state that the STATE above information is correct.I agree to comply with all County N LICESE NIS � Q2-0 ordinances and State laws regulating Heating, Ventilating ;md Air Conditioning,and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE ' County to enter upon the above-mentioned property for 'nspect,;.h purooses. Q Si,nature of Permittee Date