HomeMy Public PortalAbout6267 HART AVE_Mechanical__ 76A364C' p p
WORKERS'COMPENSATION DECLARATION A P P L4.C AT I O 9 np� FO k. P,E R nn�ff'.
I hereby affirm that I have a certificate of consent to self CE $�$(2 80J'
insure, or a certificate of Workers'convensation Ins u ce,or a-1fQy1R�G.b1✓ TILiTFWCv-A1�3 CQFd®'1YI0Pd11�I�"v .
a.gei`ti?i p:1'tifi Pof{Sec.3500> ./ � _ •
olicl� Compan w
ertfied copy is hereby furnished:
COUNTY OF LOS'AIV S UILDING AND SAFETY
Certified copy is filed with the county building inspection BUILDING �
L- -FOR APPLICANT TO FILL IN' //�� 7
department. ADDRESS' C._k" /
Date 'Applicant (PRINT,OR-TYPE ONLY) ---
'- � LOCALITY
CERTIFICATE OF EXEMPTION 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, � d
c'sr�
by the permit is for one hundred dollars ($100) or less.). DISTRICT No:, PROCEESsEgAryOU
I-certify that in the performance of the work for Which this - AIR HANDLING UNIT,CFM' cc
permit is issued, I shall not employ any person in any manner
Date to become-sl - ect to+ha W-rker ' IJ.am,e .sation Laws. 'B01LEA,BTU
so as-. W
APPROVALS DATE INSPECTOR'S SI ATURE U
A a
�2pam,licanf_ _ _ __ COMPRESSOR, BTU ROUGH LA
�—.—
NOTICE TO APPLICANT: If, after making this Certificate of vENTILATION:SYSTEM
Z .
Exemption; ,you should become subject to the Workers' FINAL
Compensation provisions of the Labor Code, you must f =
with comply with such provisions, or this`.permit shall be, EVAPORATIVE COOLER. VALIDATION
deemed revoked. FURNACE: _` FAU' GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR, BTU G%� �•
I hereby affirm that.I am licensed under provisions of Chapter HEATER:. SUSPENDED UNIT
9 (commencing with Section '7000)of Division 3 of the Busi- ` "1 WALL
ness and Professions Code, and my license is in'full force and
effect. nn /
License Number _Jo_-L _16 Lic.Class � -
�,
�r- e_s Bate
'Contractor - ,. ` , .•." s. • '
1 1 am exempt from,the licensing requirements'as I am a
licensed architect. or a 'registered professional engineer 'Plan-Check fee 25%Of 3bOVe.
acting in my professional -capacity (Section 7051, Bus-
MIT
mess and Professions Cod e): - PERMIT ISSUING FEE$
Lic.or Reg.No. DateJ.
TOTAL FEE-
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- ;
nes,and Professions Code)c. ADDRESS
Ell, as owner of the property,will do the work and the CITY "
structure is not intended or offered for sale (Section TEL. NO
7044, Business and Professions Code).
h OWNER 4lr/.� II 0,2.A
U. �`2
❑ ISect owner`of the property, am exclusively contracting ••• ,t
with licensed contractors to construct the.' project MAIL - 2_4-
( ion 7044, Business and,Professions Code). ADDRESS ( - #.a o:o.o �l'1'
CITY GI EL.NO.
CONSTRUCTION LENDING AGENCY 010, Q Q "
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is CONTRACTOR 7 _
issued(Sec-3097,Civ.C.): E 0 .
Lender's Name ADDRESS GG (� /°/�I�! y
• 0-,��- v_ '� "�.10,.2.7-,8,0.�
Lender's Address CITY /L TEL.NO. �V i� -.
I certify that I have read this application and state that the STATE / LIC. /
above information is correct.I agree to.comply with all County LICENSE-NO-3���r— CLASB (�
ordinances and State laws regulating Heating, Ventilating and
Air Conditioning; and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
County to er:er upon the above-mentioned property for
' �nsnertion pur;t ses. � ..
Sig,ht-ure of Permittee Date