HomeMy Public PortalAbout6142 IVAR AVE_Mechanical__ �_,_.Y,
Fs 2S COMPENSATION DECLARATION CEA g 8C(2-80) /r-�laf'P LC A T�O�V 'Ir-O R If�E R�j O T- ,
I- iii that 1 have a- certificate of consent to self.
insuerti€irate of Workers'Compensation Insurance,or
a certified copy thereof(Sec. 3800,Lab HEATING-NENT ILATING-All CONDITIONING C.�
=Policy NQ-14WAa16-CompanySr
❑" Certified copy is'herebx furnished: 4 COUNTY OF,LOS ANGELES BUILDING AND'SAFETY
Certified copy is f%ted with the county.building-inspection BUILDING
dep rtme t ��i, ® a FOR APPLICANT TO FILL 1N
(PRINT OR TYPE ONLY) ADDRESS _
Dare _:Applicant
--, •
LOCALITY �
CERTIFICATE OF EXEMPTION FROM WORKERS' NO, TYPE OF APPLIANCE OR EQUIPMENT FEE
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' COMPENSATIONANSURANCENEAREST.
�.. a
' CROSS ST.
(This,section need not be'Completed if the work involved ABSORPTION UNIT,BTU• '-_ '
by' the permit is for one hundred'dollars ($100) or less.) - DISTRICT NO. PROCES ED BY 0
:1 certify that in the performance
the work for which this AIR HANDLING,UNIT CF.M - c
permit is-i"ssued, I shalt not employ any-person in any manner 0
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.so as to become subject to the Workers' Compensation,Laws. BOttER, BTU
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Date` APPlicant- p U ld R E 0-
•': h APPROVALS'. DA IN TO 'S SIGNATURE
COMPRESSOR, BTU'—'l t?J- Q �i
,NOTICE TO APPLICANT: lf, after,'mak ing this Certificate of VE.NTILATtON SYSTEM D I - z
ROUGH
Exemption,..;'you should, become subject to the Workers' FINAL , _
Cortipensation provisions`of the Labor Code, you must.for*th EVAPORATIVE COOLER
With comply with''such provisions or this permit shall' be
.deemed revoked. AU GRAVITY
—
FLOOR:
FURNACE: F GRAVIT t
LICENSED`CONTRACTORS DECLARATION FLOOR. BTU C�
I herebyaffirm that lam licensed under rovisions of Chapter HEATER: SUSPENDED' UNIT
9'-(conYmen'cing,with Section.9000).of Division 3 of'.It WALL '
ness and,Prbfessf6Iis Code,and my license is-in full force and
� � u�� s 5
effect. � Q - ' -
License Number �� I�� Iic.Class= �'2Q
Contractor �_ tuatd _ -
a. I am exempt from the licensing' req emenis a, Iram a
'licensed architect or. a registered professional engineer. Plan Check fee 255%of above.
acting in my'professional capacify (Section'7051, Bus
iness and Professions Code). PERMIT ISSUING FEE$ '
Lie.or Reg.No. .. Date T_ TOTAL FEE
HOME OWNER-BUILDER�DECLARATION'.
PLAN CHECK APPLIC4,NT
1, hereby :affirm that i am exempt from--the 'Contractor's. NAME (,.
License Law for•the-fllowing reason (Section 7031.5, Busi- - a - Ie�- w
n`ess and Professions Cade): AD:DRESS:'t� W � �` t 46
I as owner of the property, will do•the work.and the. ) 1 €'I
+r. CITY TEL.NO.
y a
structure is not intended or,offered for sale.(Section .Ci L ��lp ?`�j -'� �
7044,:Business and Professions Code): `t ~ � 1 l`"'lL
I, as owner of the property,_am exclusively--contraciing OWNER . �n �' v� ` a - -
1 l I� r
with licensed contractors to construct' the project MAIL t r a
(Section 7044,•Business and Professioas.Code), ADDRESS MANGLE GLE °Q0 `
CONSTRUCTION LENllING AGENCY. ITYI TEL.NO.(
I hereby affirm that there is a construction lending agency` rte'
fo'r-the performance of the work for which this permit ,is CONTRACTOR i �,tiwt7�IC �Gj laliw, € ?v F ;r-r ft,>'
issued(Sec. 309.7,Civ.C.) L� `'��T t
Lenders Name ADDRESS �� G� Of
vV � j ft'- i . ill;IS
Lender's Address
-. CITY TEL. NO: -
1 certify that I have read this application and state that the STATE yam' LIC.' �++
abbve:information is correct. I agree to comply with all County LICENSE ND. �"��� CLASS L/_1
• ordinances and State laws regulating Heating, Ventilating and
Air Conditioning,and hereby,authorii&'representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
County to enter upon the above-mentioned property for
�ispection purposes:. .<
Signature of Permittee Date