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Home My Public Portal About6100 IVAR AVE_Mechanical__ iR ,:l't I kOv a certificate DECLARATION AG° PUC�Q`� N FOR I�LSII�II1V T �etAby aff�m that 14,oVA a certificate . .f'�-onsent to self ora cAorfied;Iti to of (Sec. 3800, Lbb:ns)ion Insurance, HEATING - VENTILATING - AIR CONDITIONING 76A3818 CE-818(REV. 10/81) ' icy No. Company ❑ Certified copy is hereby furnished. COUNTY OF LOS ANGELES' BUILDING AND SAFETY r_1 Certified copy is filed with the county.building inspec-. FOR APPLICANT TO FILL IN BUILDING �'(1 hon department.. ADDRESS ®o .� V v (PRINT OR TYPE ONLY) Date Applicant LOCALITY &"&r NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATEOF EXEMPTION FROM WORKERS' NEAREST COMPENSATION INSURANCE CROSS ST. hi— ABSORPTION UNIT, BTU DISTRICT NO. PROCESSED BY (This section need not be completed if ihe'work involved by the permit is for one hundred dollars($100)or less.) 6 I certify that in the performance of the work for which this' AIR HANDLING UNIT,CFM Perm is issued, l shall not employ person in a nne BOILER, BTU so as to become subject to'the W fS' -0 en w . APPROVALS DATE INS C R'S SIGNAT RE ,A ;Q I COMPRESSOR, BTU 0� ROUGH Date v u Applican NOTICE TO APPLICANT: If, a ing thi ter' ' e of VENTILATION SYSTEM FINAL Exemption, you should become subject to th orkers' v Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VAL DAT N with comply with such provisions or this'permit shall be deemed revoked. FURNACE: FAU GRAVITY LICENSED CONTRACTORS DECLARATION FLOOR BTU I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT '(commencing.with Section 7000) of Division 3 of the Business WALL and Professions Code,and my license is in.full force and effect. O License Number Lic. Class D U Contractor Date O ❑ _ U I am exempt under Sec. Plan check feeIL B.BP.C. for this reason H� PERMIT:ISSUING FEE$ Date: 22323,9A Signature TOTAL FEE �, OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT # o o•o 0 0 8 I hereby affirm that I am exempt from the Contractor's License D I NAME a 030.50 Law for the following reason (Section 7031.5, Business and Pr fessions Code): '0 0 0 3 Q 5 p C6 I, as owner of the property, or my employees with ADDRESS V wages as their sole compensation,will do the work and I. Q 2 2=8 5 the structure is not intended or offered for sale(Section CIT al TEL. NO. 7044, Business and Professions Code). OWNER "❑ I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec- MAIL tion 7044, Business and Professions Code). ADDRESS CONSTRUCTION LENDING AGENCY CITY TEL. NO. I hereby affirm that there is a construction lending'agency for the performance of the work for which this permit is issued CONTRACTOR ©GUNC�R- D (Sec. 3097, Civ. C.). •x ADDRESS -- Lender's Name CITY _ _ TEL. NO. Lender's Address I certifythat I have read this application and state that the STATE LIC. pp LICENSE NO.- above O:above information is correct. I a e to comply with all County ordin ces and ate laws re t' g to building construction, i d re y au re fives of this County to enter K th abo e oper or inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE gnature of Applica o A ent Date - - - - -