HomeMy Public PortalAbout5019 MCCLINTOCK AVE_Mechanical__ `1 v<'ORrIERS'COMPENSATION DECLARATION I 7SA364C pp /� g� N
1 hereby •qf sm ;hat,I have a' certificate of consent to self I CE-818(2-80) I�0`s P`i I®II�l FOR PERMIT
insure,or a certificate of Workers'Compensation Insurance,or HEATING-VENTILATING-AIR CONDITIONING
a 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 tt�e county building inspection BUILDING
dep_artme��_�nt////,,����'� e�/1J!u� FOR APPLICANT TO FILL IN ADDRESS D��
Date L��Applicant- � >• �.a (PRINT OR TYPE ONLY)
LOCALITY E+
CERTIFICCATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
I
COMPENSATION INSURANCE NEAREST }
(This section need not be completed if the work involved ABSORPTION UNIT,BTU CROSS ST. a0
by the permit is for one hundred dollars ($100) or less.) DISTRICT NO PROCESSED B (�
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM �,�`Y
permit is issued, I shall not employ any person in any manner ``J v PPP O
so as to become subject to the Workers'Compensation Laws. BOILER, BTU
APPROVALS DATE INSP, CTOR GNA RE L!J
Date Applicant COMPRESSOR,BTU ROUGH d
N
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM2
Exemption, you should become subject to the Workers' FINAL
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDAT
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 HEATER: SUSPENDED UNIT8 4 8 3 A
9 (commencing with Section 7000)of Division 3 of the Busi- WALL
ness and Professions Code, and my license is in full force and # 0 0 0 0 0 8
effect.
License Number�'�`�^�'�d Lic.Class C 'e 3 o - 2Q50
0 C33:
Contra
cDate / 0 0 0 2 a 5F1I a*294��
exempt from the licensing requirements as I am a 1 202-87
licensed architect or a registered professional engineer Plan check fee 25%of above.
acting in my professional capacity (Section 7051, Bus-
iness and-Professions Code).
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
❑ 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).
❑ Q W N E R Lryl,2^ Lvr�w�L/
I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project MAIL
(Section 7044,Business and Professioas Code). ADDRESS
CONSTRUCTION LENDING AGENCY CITY EL.NO.
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is CONTRACTO
issued(Sec.3097,Civ.C.).
Lender's Name ADDMSS �12pr /jjw..Lender's Address CITYTEL.NC 2&�L—J—
I certify that I have read this application and state that the ST E ^� LIC
• 36
above information is correct.I a ee to comply with all County LICENSE NO. �'Y f^ / CLASSY�+
ordinances and State laws reg sting Heating, Ventilating and
Air Conditioning,and h b uthorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
County to rrter u n114 above= rbperly for
inspection p oses
Signature of Permittee Date e 40000F
i