HomeMy Public PortalAbout5039 HELEO AVE_Mechanical__ sWOR'CFRS'COMPENSATION DECLARATION 76A354C APPLICATION
PPLICpyN FQ R PERMIT
CE 818 (2-80)
1'dirhnlhat 1 have acertificate of consent to self
msuredr•a cert:11cate of Workers'Comnensation Insurance,or HEATING-VENTILATING-AIR CONDITIONING
certiff d copy thereof(Sec,3907ylab-C_.) -�f
PolicyNcQRu, l7F7�opany-T.•-!Zflij✓i-C�Yf%`
❑ Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with the county building inspection 14" p FOR APPLICANT TO FILL IN BUILDING 7q
de art mens. ,1 ,�O ��J 1 �v
Date— Applicant _ _ _Ale, (PRINT OR TYPE ONLY) ADDRESB 1 _
3/IH tgy "G'i/ LOCALITY T
CL•RTIFICnf_OF EXEMPTION FROM WORKERS' NO, TYPE OF APPLIANCE OR EOUIPMENT FEE ` ,t
COMPENSATION INSURANCE NEAREST J - ._ -, _
(This section need not be completed if the work involved ABSORPTION UNIT, BTU— CROSS ST.�^\7�V"-�i�/ �"� a.
by the permit is for one hundred dollars ($100) or less) DISTRICT NO. CE. EDBY O
1 certify that in the performance of the work for which.this AIR HANDLING UNIT,CFM a,OpQ DO ,y/� L)
permit is issued, I shall not employ any person in any manner V9 0
O
so as to become subject to the Workers' Compensation Laws. BOILER, BTU
' / APPROVALS DA E IN ..TOR's SIG'AT _ U
Date Applicant COMPRESSOR,BTU 4 Q ,A 9 k9 ,06
ROUGH
NOTICE TO APPLICANT: If, after making this Certificate of _ U)
Exemption, you should become subject to the Workers' VENTILATION SYSTEM FINAL - Z.
Compensation provisions of the Labor Code, yEVAPORATIVE COOLER VALI ..WV must forth-
with comply with such provisions or this permit shall he y t
deemed revoked. FURNACE: FAU—P— RAVITY_ T 1�`dt
LICENSED CONTRACTORS DECLARATION FLOOR: 8TU_lpa0_}-'f O QO �.�I ! 4'j.
I hereby affirm that 1 am licensed under provisions of Chapter HEATER: SUSPENDED UNIT ITEMS.
9 (commencing with Section 7000)of Division 3 of the Busi- WALL _
ness and Professions Code, and my license is in full force andT I 40 -50
effect
. �I"AI"
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�.NE'•:K 'TG.s�l
License Numbe,— '( 7^�_ Lia Class_ ����'^� f'
�u/t�rO ate 3//� l CHANGE X i
Contractor_ t _
❑ I am exempt from the 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 $ /Q Q qa
Lic.or Reg.No. Date TOTAL FEE _ 1 51 1 �� '-"�'1
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
❑ 1, as owner of the property, will do the work and the CITY TEL. NO.
structure is not intended or offered for sale (Section
7044, Business and Professions Code).
❑ I, as owner of the property, am exclusively contracting OWNER
with licensed contractors to construct the project MAIL
(Section 7044, Business and Professions Code). ADDRESS
CONSTRUCTION LENDING AGENCY CITY TEL.NO.
1 hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is CONTRACTOR
issued (Sec. 3097.Civ.C.).
Lender's Name ADDRESS '
Lender's Address CITY TEL. NO.
1 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. CLASS
ordinances and State laws regulating Heating, Ventilating and
Air Conditioning, and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
County to enter upon the above-mentioned property for
inspection purposes.
Signature of Permittee Date _