HomeMy Public PortalAbout6350 OAK AVE_Mechanical__ 1 p •
,j\VQR,�KI? 76A364C A
RS'COMPENSATION DECLARATION 7B - 64 (2 80) P P L� C AT Q O �1 FOR P E R N�'U T
I hereby affftrm that I have a' certificate of consent to self
insure,or a certificate of Workers'Compensation Insurance,of I HEATING-V ENTILATIR(G-AiR CONOITIONING
a certified copy thereof(Sec.3800,Lab.C.)
Policy No.31`� d Company
El Certified copy is hereby furnished. COUNTY OF LOS ANGELES , �'' BUILDING AND SAFETY
1
Certified copy is filed with the county building inspection BUILDING
,I a_r�t�ep�"t. i FOR APPLICANT TO FILL IN t
Date.f0='a a Applicant ��-� (PRINT OR TYPE ONLY) ADDRESS 1(f
��
C'I-,RTIFICATE Of EXEMPTION FROM WORKERS' NOg4lt le/e_ jrX
! TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY 1
COMPENSATION INSURANCE NEAREST
(This section need not be completed if the work involved ABSORPTION UNIT, BTU CROSS ST. IL
by the permit is for one hundred dollars ($100) or less.) DISTRICT NO. PROCESS D BY ` O
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM
permit is issued, I shall not employ any person in any manner j b 1l o� 0
so a:, to become subject to the Workers' Compensation Laws. BOILER,BTU
� APPROVALS DATE INSPECTOR'S SIGNATURE V
Date Applicant COMPRESSOR,BTU 924006 _,I n.� a
NOTICE TO APPLICANT: If, after mROUGH making this Certificate of I VENTILATION SYSTEM N
Exemption, you should become subject to the Workers' -FINAL �c� �r -ti_. Z
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLS
with comply with such provisions or this permit shall be / VALIDATION
deemed revoked. FURNACE: FAU
LICENSED CONTRACTORS DECLARATION ( FLOOR: BTU
I hereby affirm that I am licensed under provisions of Chapter HEATER: SUSPENDED UNIT
9 (commencing with Section 7000) of Division 3 of the Busi- WALL
•ness and Professions Code, a d my license is in full force and
effect. '
License Numbers Y Lic.Class
Contractor = Date 1I-
❑ I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer Plaq check fee 25%of above.
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code). PERMIT ISSUING FEE$
Lic.or Reg.No. Date TOTAL FEE `� b
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from-the Contractor's NAME v� r
License Law for the following reason (Section 7031.5, Busi-
nesti and Professions Code)- ADDRESS � �� LLMC
❑ 1, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section CITY ,0�-TEL.NO. 7 l ,
7044, Business and Professions Code). ,4 3 0.7 A
OWNER
❑ I, as owner of the property, am exclusively contracting {'# 0 0 0 0 o 8with licensed contractors to construct the project MAIL
(Section 7044, Business and Professions Code). ADDRESS
4 3 5 0
CONSTRUCTION LENDING AGENCY CITY TEL.NO.
I�•�'"`
I hereby affirm that there is a construction lending agency CONTRALTO ,
O Or U
C
for the performance of the work for which this permit is j
issued(Sec. 3097,Civ.C.). (j�6 0�tt_8 2
Lender's Name ADDRESS
Lender's Address_ CITY TEL.NO.
I certify that I have r•ad this application and state that the STATEI LIC. &3
above information is correct.I agree to comply with all County LICENSE NO. 1140 0 CLASS
ordinances and State laws regulating Heating, Ventilating and
Air Conditioning, and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
County to'enter ups the above-mentioned property for
r+ pection purposes. `—if/—
signature of Permittee Date