HomeMy Public PortalAbout6132 OAK AVE_Mechanical__ ' x'70•lir-RS'CO-,1PF.NSAI ION DECLARATION AB 8CJ
(2-BO) APPLICATION FOR PERMIT hereby affirm that I have certificate of consent to self CE
insure, or a certificate of Workers'Compensation Insurance,or BEATING-VENTILATING-AIR CONDITIONING
a certified copy thereof(Sac. 3800,Lab C.) C�) "fl
CCA
PolicyCompany COUNTY OF LOS ANGELE BUILDING AND SAFETY
Certified copy is hereby furnished.
Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN (BUILDING
department. `
613,1
Date Applicant (PRINT OR TYPE ONLY) ADDRESS C7Z/
LOCALITY �
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE f
COMPENSATION INSURANCE NEAREST }
(This section need not be completed if the work involved ABSORPTION UNIT, BTU CROSS ST.`,�1 f (!L7(j Jam'Y 0
by the permit is for one hundred dollars ($100) or less.) DISTRICT NO. PR ssE By U
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM � �j � cc
permit is isseted. I shall not employ any person in any manner TJ O
so as to become subject to the Workers'Compensation Laws. BOILER, BTU
APPROVALS DATE INSPECTOR'S SIGNA E W
Date Applicant COMPRESSOR,BTU ROUGH y
NOTICE TO A YLICANT: If, after making this Certificate of VENTILATION.SYSTEM e z
Exemption, you should become subject to the Workers' FINAL
Compensation provisions of the Labor Code, you must forth-
with comply wEVAPORATIVE COOLERith such provisions or this permit shall he VALIDATION
deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter HEATER: SUSPENDED UNIT
9 (commencing with Section 7000)of Division 3 of the Busi- WALL
ness and Professions Code, and m)• license is in full force and
effect.
License Number Lic.Class
Contractor Date
\ El 1 am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer Plan check fee 25%of above.
acting in m) professional capacity (Section 7051, Bus-
iness and Professions Code). PERMIT ISSUING FEE$
Lic.or Reg.No. Date TOTAL FEE i
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 Coda): 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
;K7 44, Business and Professions Code). oe
OWNER
as owner of the property, am exclusively contracting
th' licensed contractors to construct the project MAIL
(Section 7044,Business and Profession.,-Code). ADDRESS
CONSTRUCTION LENDING AGENCY CITY TEL.NO. 1 'J Z.7 A
I hereby affirm that there is a construction lending agency CONTRACTOR 0 0 0 0 �.
for the performance of the work for which this permit isV elf
issued(Sec.3097,Civ.C.).
Lender's Name Gd-, ADDRESS 2 c - 2700
Lender's Address „ 6 CITY TEL.NO. Io 0 0 2 7,n(r
1 certify that 1 have read this application and state that the STATE LIC.
above information is correct. I agree to comp]) %Kith all County LICENSE NO. CLASS D 7 1 7-8r-
ordinances
—$iordinances and State laws regulating Heating, Ventilating and
Air Conditioning,and hereby authorise representutives of this SEE REVERSE FOR EXPLANATORY LANGUAGE.
County to enter upon the above-menti ed proper y for
inspection pu:p /;
1
Signa mi.tee Date l