HomeMy Public PortalAbout5232 MCCLINTOCK AVE_Mechanical__ 76A364C
WORKERS'COMPENSATION DECLARATION CE-816 (2-80) APPLICATION FOR PERMIT
nhereby affirm that I have a' certificate of consent to self
insure, or a certificate of Workers'Compensation Insurance,or HEATING-VENTILATING-AIR CONDITIONING
a certifie/j,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 C
department. FOR APPLICANT TO FILL IN BUILDING '
O
Date Applicant (PRINT OR TYPE ONLY) ADDRESS ICL/�'
LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS'
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE to
COMPENSATION INSURANCE NEAREST
(This section need not be completed if the work involved ABSORPTION UNIT, BTU CROSS ST. d
by the permit is for one hundred dollars ($100) or less.) DISTRICT NO. PROCESSE 1 U
1 certify that in the performance of the work for which this AIR HANDLING UNIT,CFM
permit is issued, I shall not employ any person in any manner I . I Cr41
so as to become subject to the rkers' Co ensation Laws. BOILER,BTU
APPROVALS DATE INSPECTOR'S SIGNATURE V
Date 21)plicant � COMPRESSOR,BTU �`�`t QI/�! D a
NOTICE TO APPLICANT: If, after making is Certificate of VENTILATION SYSTEM ROUGH FINAL L' Z
Exemption, you should become subject to the Workers' _
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER 1t r�
with comply with such provisions or this permit shall be Q�9 01 �[�/� VALIDATION
�eemed revoked. (/J
FURNACE: F.AU GRAVITY
LICENSED CONTRACTORS DECLARATION I FLOOR: BTU Cjo
I hereby affirm.that I am licensed under provisions of Chapter I HEATER: SUSPENDED UNIT Q
9 (commencing with Section 7000)of Division 3 of the Busi- WALL
ness and Professions Code, and my license is in full force and
effect. �1G
License Number 2 Lic.Class
Contractor 1)6-IJ 0A4.9►"Q D to- a i s,—F o
❑ I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer Plan Check fee 25%Of above.
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code). PERMIT ISSUING FEE$
Lic.or Reg.No. Date I 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 I ;
structure is not intended or offered for sale (Section i CITY TEL.NO.
7044, Business and Professions Code).
El 1, as owner of the property, am exclusively contracting OWER Q LD Gr ` C 6 2 7
with licensed contractors to construct the project MAIL -7
(Section 7044,Business and Professions Code). I ADDRESS 2 J Z A e CLI '� C 0 0 0 0 [(
CONSTRUCTION LENDING AGENCY i I CITY �L Lol �- TEL.NO 0 - 27,00 200
I hereby affirm that there is a construction lending agency
for the.performance of the work for which this permit is I , CONTRACTOR �� L .�ar.r✓� o 0 0 .�' ;
issued SSec.3097,Civ.C.).
Lender.s Name i ADDRESS Z(.5 8 0
Lender's Address 1 CITI!�0 TEL.NO. t—,91 4
i
1 certify that I have read this application and state that the STAE �+ LIC.
above information is correct.I agree to comply with all County LIC ISIS
NO. ! CLASS 'S�O
ordinances and State laws regulating Heating' Ventilating and ,
Air Conditioning,and hereby authorize representatives bf this SEE REVERSE FOR EXPLANATORY LANGUAGE
County to enter upon the above-mentioned property for
Aection pr ses.ature of 5k
ittee Date