HomeMy Public PortalAbout5426 HILTON AVE_Mechanical__ 'LOR KE RS'COMPENSA:YON DECLARATION CE 81C APPLICATION ION rOPERMIT
I hereby affirm that I have a Certificate of consent to self CE-818(2-80) lf"'(
insure,or a certificate nT Workers'Compensation Insurance,or HEATING-V ENTILATI NG-AIR CONDITIONING �tUl
h�¢orJ,-,.r tc�Nr����(p�0o. L•- C—7
Policy No.—r ComP.nyG� �
❑ Certified copy is hereby furnished. COUNTY OF LOS ANGELES / / BUILDING AND SAFETY
xCertified copy/is filed withthe county
{In " Ing inspection FOR APPLICANT TO FILL IN BUILDING
Date.�ro(. i AppIica <J�/ / e�'�=G"J (PRINT OR TV PE ONLY) ADDRESS �j /�• ��/LOCALITY T, ,, • G, �i
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. a Gy CL
by the permit is for one hundred dollars ($100) or less.) DISTRICT NO. PROCESSEr ay (�
I certify that ithe performance of the work for which this AI R HANDLING UNIT,CFM_ L� V ' �`l 0
permit is issued,, I shall not employ any person in any manner /j�,�,� a O
so as to become subject to the Workers' Compensation Laws. / BOILER, BTU_
APPROVALS DATE INSPECTOR'SSIGNATURE U
W
Date Applicant COMPRESSOR,BTU - y
ROUGH �[
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM o---" Z
Exemption, you should become subject to the Workers' FINAL
Compensation provisions of the Labor Code, you must forth EVAPORATIVE COOLER VALIDATION
with comply with such provisions or this permit shall be
deemed revoked. GRAVITY—
LICENSED
/ /J /
LICENSED CONTRACTORS DECLARATION FURNACE: FAU_ GRAVITY_ 6 / f/
FLOOR: BTU
I hereby affirm that 1 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. �^�./',� �
License Number—/�fl,�°J--/�(`�l�`j Lia Class
ContractC.477 _ _ W Date
❑ I am exempt from the licensing requirements as 1 am a
licensed architect or a registered professional engineer Plan check fee 25%of above.
acting in my professional capacity (Section 7051. Bus. ,r
iness and Professions Code). PERMIT ISSUING FEES -/
Lie.or Reg.No. Date TOTAL FEE --1317
—
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT ep —n—ck
I hereby affirm that 1 am exempt from- the Contractor's NAMELicense 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 CITY, 1�{. I TEL. N�(i4�\A�
structure is not intended or offered for sale (Section I
7044, Business and Professions Code). r r
❑ 1, as owner of the property, am exclusively contracting OWNER `l � 0,5 2,91A.
with licensed contractors to construct the project MAIL J /�{{�
(Section 7044, Business and Professions Code). ADDRESS . _7 - #,e�ele o [(_1
CONSTRUCTION LENDING AGENCYCITY TSL. 2 o io 27.010
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is CONTRACT' /
issuedSea Civ.C.). /
` c�-�t.F � d�C�..l� e.o e27.00�
Lender's Nameme ADDRESS r�D ✓J .
0A.28781
Lender's Address CITY 1 TEL.NO//
1 certi. that I have I:ad tis application and state that the ST '!E LIC.0
above infoi ' . rrect. .agree to comply with.all County LIC =NSE NO. �� �_3 CLASS�`�
ordinances State Iws rel ilating Heating, Ventilating and
Air CoD'.(,oni,.-,and , ereby adhorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
C. ,- ,. _i m t above-mentioned property f r
inspe 'inn {. Iry
Signature of Permittee