HomeMy Public PortalAbout4964 MCCLINTOCK AVE_Mechanical__ ' 4 76A364Cp 2 (� �j'
,. ii'ORKERS'C01'1PENSATION DECLARATION CE-818(2-80) �P P pp L� C A T�0 �I FOR P E R uvu u
I %*�ehy ffirivi that I leave a c@rtificate of consent to self
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tnsu.e, or a certificate of Workers'Compensation Insurance,or HEATING-VENTILATING-AIR CONDITIONINGa certified copy thereof(Sec.3800,Lab.C.)
Policy No. Company
❑ Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with the county building inspection
❑ FOR APPLICANT TO FILL IN BUILDING
department.
Date Applicant (PRINT OR TYPE ONLY) ADDRESS L
�— �-
LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE - , �!�
COMPENSATION INSURANCE NEARES
(This section need not be completed if the work involved ABSORPTION UNIT,BTU CROSS ST. O
by the permit is for one hundred dollars ($100) Or less.) DISTRICT NO PROCESSED 1Y f„)
I certify that in the performance of the work for %%hick this AIR HANDLING UNIT,CFM 1 el cc
permit is issued, I shall not employ any person in any manner 0
so as to become subject to the Workers' Compensation Laws. BOILER, BTU __ _
APPROVALS DATE INSPE TOR'S GNATURE W
DatApplicant, �+ �� _ COMPRESSOR,BTU ROUGH C16
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. FURNACE: FAUAVITY
LICENSED CONTRACTORS DECLARATION
FLOOR BTU7! .n®D oD
1 hereby affirm that I 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. LL
License Numbed? V Z Lic.Class�� �' 13 2 0 A
MaCo or n r"4 Date�L_'-�✓ # 0 0 0 0 o a
❑ 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 profession;capacity (Section 7051, Bus- PERMIT ISSUING FEE nJ loo 3 Q 5 0
iness and Professions Code). _
Lic.or Reg.No. Date TOTAL FEE o 0 o 3 a 5 0 t=i
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT 01. 09-85
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
❑ I, as owner of the property, will do the work and the CITY TEL.NO.
structure is not intended or offered for sale (Section
7044, Business and Professions Code). t
F-11,I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project MAIL
(Section 7044,Business and Professions Code). ADDRESS u
CONSTRUCTION LENDING;AGENCY —IT
TY TEL.NO.
I hereby affirm that there is a construction lending al,ency CONTRACTOR --
to
for the performance of the work for which this permit is
issued(Sec.3097,Civ.C.). — ,..�"—
Lender's Name ADDRESS �O
Lender's Address _ C TEL.NO.
I certif that I have read this application and date thof the
} pp [nSTATE 7� /7
above information is correct.1 agree to copl} ssi[h:III County LICENSE NO. 4r J CLASS
ordinances and State laws regulating Heating. Ventilating and -2!5-k
Air Conditioning,and hereby authorize representatives of this SLL RLVhRSE YOR EXPLANATORY LANGUAGI"
County to enter upon the above-mentioned propest�} �for
insp ct" �rD� I d�_ 1 +
Signature of Permittee Date