HomeMy Public PortalAbout6122 OAK AVE_Mechanical__ 11'ORJJrRS'C OMPI.NSATION DECLARATION CEA 8 8(2-80) A D P L IC AT 0®II V FOR fT"E R 11�7'I!IT
I hereby affirm that I have a' certificate of consent to self
insure, or a certificate of Workers'Compensation Insurance,or HEATING-VENTILATING-AIR CONDITIONING
a certified copy thereof(Sec.3800,Lab.C.) "fl
Policy No. 580932 Company St�.tD
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is hereby furnished.
® Certified copy is filed with t uu y buildg inspection FOR APPLICANT TO FILL IN BUILDING
department. ADDRESS
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Date 9_—JJ—C?Applicant (PRINT OR TYPE ONLY)
LOCALITY
CERTIFICATE OF EXEMPTION rROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
COMPENSATION INSURANCE NEAREST
(This section need not be completed if the work involved ABSORPTION UNIT,BTU CROSS ST. C
by the permit is for one hundred dollars (5100) or less.) — DISTRICT NO. PROCESSED BY U
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM �D p
permit is issued, I shall not employ any person in any manner O Cc
so as to become subject to the Workers' Compensation Laws. BOILER,BTU O
APPROVALS ATE SPECTOR'S SIGNATURE V
Date Applicant COMPRESSOR,BTU 3 6 t – L" W
ROUGH fl
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL 2
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth-
with comply with such provisions or this permit shall be EVAPORATIVE COOLER VALY6A ION
deemed revoked.
LICENSED CONTRACTORS DECLARATION � FLOOR, FA RAVITY
BTU / l
I hereby affirm that 1 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. 0 d e,7 BD
License Number 274880 Lic.Class 20
Contract _ Date 9-11—A1
F1 I am exempt from the licensing requirements as 1 am a y�
licensed architect or a registered professional engineer Plan check fee 25%of above.
acting in my professional capacity (Section 7051, Bus-
iness and Professions Cade). PERMIT ISSUING FEE$ 13 e-o
Lic.or Reg.No. Date TOTAL FEE
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that 1 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 do the work and the
CITY TEL
structure is not intended or offered for sale (Section C .NO. __
7044,Business and Professions Code). -1-
OWNER
1, as owner of the property, am exclusively contracting I _,
with licensed contractors to construct the project MAIL
(Section 7044,Business and Professions Code). ADDRESS �,_I,�}� 1, :A
CONSTRUCTION LENDING AGENCY CITY TEL.NO. -
-.�.t e•tel_
I hereby affirm that there is a construction lending agency _
for the performance of the work for which this permit is CONTRACTOR J t:i ii"13� ,yl._
issued Sec.3097,Civ.C.).
Lender s Name ADDRESS
Lender's Address CITY TEL.NO.P S ;'j_„!�
1 certify that I have read this application and state that the STATE LIC. yC;o i=
above information is correct.I agree to comply with all County LICENSE NO. CLASS
ordinances and State laws regulating Heating. Ventilating and
Air Conditioning,and hereby authorize representatives of this SEL' REVERSE FOR EXPLANATORY LANGUAGE
County to enter upon th above-mentioned property for
inspec ' pur oses.
Signet re of Permi tee Date