HomeMy Public PortalAbout6231 IVAR AVE_Mechanical__ WORKERS'COMPENSATION D. CE 81
CLARATION C
hereby affirm that`I have a' certifiente o: consent to self CE-818 (2-80) Q`If- If� l��� Q u V FOR If�S l� r`!U��
insure, or a certificate of Workers'Compensation Insurance,or
HEATING-VENT ILATI NG-Al R CONDITIONING
t� he ofJ(,�ec. 3800,
�E.Le
1 --�5.•7 pant '
!� COUNTY Of LOS ANGELES BUILDING AND SAFETY
tified copy is hereby furnished. - ,
tified copy is filed with the count ding tion FOR APPLICANT TO FILL IN 13UILDIN �
ADORES
Applicant _ (PRINT OR TYPE ONLY)
• LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS" '
NO. TYPE OF APPLIANCE OR-EQUIPMENT FEE �~
COMPENSATION INSURANCE NEAREST
CROSS ST. �-,r
'i(This section need not be'completed if the work involved ABSORPTION UNIT, BTU _ 0 p
kby the permit is for one hundred dollars ($100) or less.) DISTRICT NO. PRO,
:S '.D BV O
I certify that in the performance of the work*for which this AIR HANDLING UNIT,CFM � !
permit is issued, I shall not employ anv erson in any manners 0
so as to become subject to therke s' ensati n Laws. BOILER, BTU
_ APPROVALS DATE NSPECTOR'S ATURE W
Applicant COMPRESSOR,BTU ROUGH \y
NOTICE TO APPLICANT: If, after making this.Certificate of VENTILATION SYSTEM z
Exemption, you should become subject to the Workers' FINAL —
Compensation provisions, of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION
with comply 'with such provisions or this permit shall be
deemed revoked. FU-RNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION F R: BTU
I hereby affirm that'I am.licensed-under provisions of Chapter HEATE SUSPENDED. UNIT
9 (commencing with Section 7000)of Division 3 of the Busi- WALL
ness and Professions Code, and my license is in full force and
effect.
License Nu per Lic.Class
Co cto J Date
I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer Plan'check fee 25%Of above.
acting in my professional capacity (Section 7051, Bus-
iness and Piofessions Code). PERMIT ISSUING FEE$
Lic.or Reg.No. Date TOTAL FEE Q
' HOME OWNER-BUILDER DECLARATION PLAN CHECK-APPLICA
I hereby affirm that. I am exempt from`the Contractor'sNAME i'
License Law for the following reason- (Section7031.5, Busi-
ness and.Professions Code): ADDRES
El I, as owner of the property, will do the work and the CITY TE
structure is ( 0:not intended or offered 'for sale Section `. o'
7044, Business and Professions Code). 55 45 0.A
O
am exclusively contracting OWNER
1, as owner of the property, # 0'0 0 0 4.1
Aa
with licensed contractors to construct the project MAIL '
(Section 7044, Business and Professions Code). ADDRESS C 2 0 f0 27,0 0'
CITY f EL.NO.
CONSTRUCTION LENDING AGENCY .0 0 0 2 7,.0 O'tzi
I hereby affirm that there is a construction lending agency CONTRACTOR
for the performance of the work for which this permit is i
issued (Sec. 3097,Civ.C.). 5,2 8 $
Lender's Name - ADDRESS
Lender's Address CITY TE
I certify that-] 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
my to enter upon the above-mentioned property.1o,
iI p on p s '�-
Signature of Perms tee Date