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Home My Public Portal About5831 OAK AVE_Mechanical__ WORKLRS COMPENSATION DECLARATION 4364C I hereby affirm that i Ita%e a certificate of consent to Self s 2 BO) APPLICATION FOR PERMIT insure or a certificate of Workers Compensation Insurance or HEATING VENTILATING All CONDITIONING a ce tified copy thereof(Sec 3800 Lab C) 77 Policy No Company COUNTY OF LOS ANGELES BUILDING AND SAFETY pCertified copv is hereby furnished Certified cop) is filed with the countl, building inspection FOR APPLICANT TO FILL IN BUILDING �j department ADDRESS'-/ Date Applicant (PRINT OR TYPE ONLY) l LOCALITY CLRTiI ICATE or EXEMPTION FROM WORKFRS NO TYPE OF APPLIANCE OR EQUIPMENT FEE NEAREST COMPENSATION INSURANCE CROSS ST%�.��►�W d (This section need not be completed if the work involved ABSORPTION UNIT BTU p by the permit is for one hundred dollars (SIOO) or less) DISTRICT NO PROCESSrD BY V I certify that in the performance of the work for which this AIR HANDLING UNIT CFMr Q� O pormit is issued 1 shall not emplo) any person in any manner J so as to become subject to the Workers Compensation La«s BOILER BTU I� APPROVALS DATE INSPECTOR S SIGNATURE Ill Applican — Z�'1. / COMPRESSOR BTU lope � ROUGH CO) NOTILI TO APPLICANT If after making this Certificate of VENTILATION SYSTEMFINAL Z Lxemption you should become subject to the Workers 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 FAU rRAVITY I iCENSFD CONTRACTORS DLCLARATION � FLOOR BTU_ilapgQ&R2-- i hereby affirm that I am licensed under provisions of Chapter HEATER SUSPENDED UNIT 9 (commencing with Section 7000)of Dnision 3 of the Busi WALL ness and Professions Code and my license is in full force andO�/ effect bt�� ` ,x I Licem nse Nu �-� Lac Class a4cor �N /= Date ( I am exempt from the licensing requirements as 1 am a licensed architect or a registered professional engineer Plan check fee 25%of above acting in my professional capacity (Section 7051 Bus PERMIT ISSUING FEE $ iness and Profession Code) d Lic or Reg No Date TOTAL FEE HOMF OWNLR BUILDFR DECLARATION PLAN CHECK APPLICANT i hereh) affirm that I am exempt from the Contractor s NAME License Law for the following reason (Section 7031 5 Busi ness Ind Professions Code) ADDRESS El1 as o%%ner of the property will do the work and the CITY TEL NO f structure is not intended or offered for sale (Section 96321 A 7044 Business ind Professions Code) OOWNER i as owner of the property am exclusively contracting # • •l• • • 8 with licensed contractors to construct the project MAIL (Section 7044 Business and Professions Code) ADDRESS —it2 • • 3 a 5 0 CONSTRUCTION LLNDING AGFNCY CITY TG TEL NO •i• . 3&5 0 1 hereby affirm that there is a construction lending agency �y'/' / for the performance of the work for which this permit is CONTRACTOR [.e 0920-82 is%ued(Sec 3097 Civ C) ��e��.! jI:/' 70 — Lender s Name ADDRESS-Ile DDRESS-e Lender s Address CITY — TEL NQ's i certify that I have read this application and state that the STATE 2-2�� LIC LO aboto information is correct i agree to comply%%ith all County LICENSE NO CLASS ordinances and State la%%s regulating Hearing Ventilating and Air Conditioning Ind hcreb) authorize representatives of this SEE Ri'Vi RSI i OR EXPI ANATORY LANGUACI County to enter upon the above mentioned pro erty for i ispe pu po s ` Signature o ermittee Date �o _