HomeMy Public PortalAbout6462 LOMA AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION CEA 8 8 (2-80) A I(- IT" L� CAT�O U V l� O IIIc If- . RYUG T
'I hereby.affirm that i have a certificate of consent to self
insure, or a certificate of Workers'Compen-ation Insurance,or
ace'tifieil r,p�rh�Ppl7/�f:j�ea 380x,La.,t / /�/� ��� HtATINO-VENTILATING-AIR CONDITIONING
Policy No. .I U/V�mpany ( 'Y'
.Certified copy is hereby Furnished. COUNTY OF LOS ANGELES BUILDING 'AND SAFETY
0 Certified copy,is filed with the coy my builf�r;inspec+ on 13UILD1NG
r• 3rtrc\F�,•rx/ �`^ fF FOR APPLICANT TO FILLJN ADDRESS
Date: _/v '+ �PPhcant. _ _�(,�J _ (PRINT OR TYPE ONLY') --
Date- Y� LOCALITY �j/A - f �• _
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT , FEE _L✓6r!�( t'/
COMPENSATION INSURANCE NEAREST
(This section need not be completed if the.work involved ABSORPTION UNIT, BTU CROSS ST.- J� O
by the -permit is for one,hundred.dollars ($100) or less.) DISTRICT NO. G� GGG PZZCESSE, 13'i U
AIR HANDLING UNIT,CFM 1
I certify,that in the performance'of the work for.which this. y v � �
permit is issued, I shall not'employ any person in any manner 00 1 O
so as to become subject to the Workers' Compensation Laws. BOILER, BTU F''
Applicant COMPRESSOR BFU 30 �. -
APPROVALS ' DATE INSPECTOR'S SIGNATURE t
Date.— Applicant
1 ROUGH Cn
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM /+`� 2
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. ��
FURNACE: . FAL _Q_ t,RAVITY
LICENSED CONTRACTORS DECLARATION FLOOR::-
I
I hereby affirm•that I am licensed under provisionsof Chapter NEATER: SUSPENDED -UNIT
9 (commencing with Section 7000)of Division 3 of the,Busi- WALL
nes&and Professions Code, and my license is in full force and
effect. (�
License umber3 E! Lic.Class; _ —
Conlr o�y I°�
1-4-iS-1-4-i -Date
QI am exempt from the licensing requirements as I am a
licensed architect or a 'registered professional engineer Plan Check fee 25%of above. PPss
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code). Q�
Lic.or Reg.No. Date -TOTAL FEE
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 db the work and the TEL. NO.
structure is not intended or offered for sale (Section CITY
7044, Business and Professions Code).
�.],.as owner of,the property, am exclusively conOWNERtracting 1
with licensed contractors to.construct the project MAIL �f
(Section 7044,Business and Professions Code). ADDRESS' 7 i9l� 7"(� v C_' o
CITY. -/rI [ EL.NO. �Y�p JCJ $35 5
CON$TKUCTION LENDING AGENCY fJ q"q
I hereby,.affirm that there is a construction Pending agency
CONTRACTOR C' _�/Z6'0' /�• Z �" "
for the performance of the.work for which this permit Is -
issued(Sec. 3097,Civ.C.):' .
('
Lender's Name ADDRESS g '� �� Lf l
Lender's
A
Icertifythatelshave read this application a �W TEL NO Q 7
CITY.�� L, y
nd state that the STATE LIC.,. Z - 7�
above informationis correct.I agree to comply with all County LLLgENSE NO. �Q CLASS
ordinances and State laws regulating Heating; Ventilating and / Z-Z19D
Air Conditioning, and hereby authorize representatives of this 'SEE REVERSE FOR EXPLANATORY LANGUAGE
County to enter . >>
upon .the a ve-mentioned property for
ii-necti.n p I poses.
Siva,t re 31 in'ttee — Date