HomeMy Public PortalAbout6374 OAK AVE_Mechanical__ E
> WORKERS?CO1vIPEhTSAT10N DECLARATION r '76A364C –" –
Ihereby-affirm that,I have a' certificate of consent to self CE-818(2-80) AP P L IC AT I®.N FO R�P • R M IT
insure,or a certificate of Workers'Compensation Insurance;o'r HEATING-VENTIL/4TIING-AIR CONDITIONING
a ccrt' a copy
thereof{Sec.3800,Lab .',
Pohcy `� Company-
^Certified copy'is hereby furnished.
COUNTY OF LOS ANGELES I �' BUILDING AND SAFETY
Certified copy'is'filed with the county building inspection FOR APPLICANT TO FILL IN BUILDING '
pa tme t. Gf PRINT OR TYPE ONLY) ADDRESS '
D3 71
ate pplicant�,s24 e�a 't (
CERTIFICATE OF EXEMPTION FROM WORKERS' LOCALITY"
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
COMPENSATION INSURANCE, NEAREST
CROSS ST. a
(This section..need not be completed if.the work involved ABSORPTION UNIT,BTU p
by the'permit is for 'one hundred dollars ($100) or less.) DISTRICT NO. PROCESSED BY U
I certify that in the performance of the work for which•this AIR HANDLING UNIT,CFM. CA �t
permit is issued, 1 shall not employ,any person in any manner �irJ O.
so"as to'become'subject to the Wdrkers'•Corapensat(on Laws. BOI.LEA.,BTU x
• ' - r'C.-' • APPROVALS DATE INSPECTOR'S SIGNATURE
Date 'Applicant COMPRESSOR BTU LU
D v0 ROUGH �8 _ e.... N
NOTICE TO.AP..PLICANT: If, after making this,Certificate.of VENTILATION SYSTEM ^ "Z'
Exemption, you ,should become subject to the Workers' FINAL _ —
Cbmpensation •provisions,of the Labor"Code, you must forth- EVAPORATIVE,COOLE.R ' ' ' t VALIDATIO
`with• comply, with such'-provisions or this permit shall'be
deemedrevoked.
FURNACE, F'AU' AV
-LICENSED CONTRACTORS DECLARATION. FLOOR: BTU 00 „
I hereby'affirm'that I am licensed dnder provisions of Chapter HEATER: SUSPENDED UNIT j
�9 (co'mmencing with Section 7000)of Division 3 of the Busi- WALL
(ness and:Professions'Co'd'e,and my license is in full force.and 02 f/
,s effect. '• � •: .� .
LicenseNuiLic.Class—
ContractorDafe '' {
aI,am exempt from the'licensing requirements as I am a
licensed architect or a registered professional engineer, Plan•CheCk.fee 25%.ofabove.
acting in my professional capacity (Section 705.1, Bus-
and Professions Code). PERMIT ISSUING FEE$ I
Lic.;or Reg.No. Date ' _ TOTAL FEE,,
HOME OWNER-BUILDER OECLARATION PLAN CHECK APPLICANT
I hereby affirin•,that I am exempt from`the Contractor's. NAME
License Law'foi the -following reason (Section 7031.5, Busi
Hess and Professions.Code): ADDRESS' t� 01,2.'A 1„L ;
11 as owner'of the property, will do the work and,fhe :CITY TEL':NO:
structure'is no't'intended or. offered for sale, (Secflon' �± o,o oe o
7044,Business and Professions Code.):
OWNER `
11-11, as owner of the property, am exclusively contracting �• 2 °`O 43,50
with licensed '.contractors• to construct . the project MAIL
(Section 7044,'B,usiness and Professions Code). ;. ADDRESS �o'.o, o =
4 3,,�5 Cl
CONSTRUCTION.LENDING AGENCY' CITY T�L.NO'. i , . s
•I hereby affirm that there• is a construction'lending-agency 2, 9,r 8
for the performance of'the,work.for which this permit is CONTRACTOR-
issuedSSec.3097,,Ci6::C.).' S
r
Lender s Name ADDRESS I
Lender's`Address CITY A4 TEL.NO. ' Q
I certify that I have read'this application and state that='the STATE. LIC. ;
above information is correct'.I.agree to cornply with-all County LICENSE NO.. ZZL942CLASS. "
ordininnes'and State. la�us.regulating Heating',Ven'tiliiting'and t
Air Conditioning,and hereby authorize:representatives,0.fthis SEE REVERSE FOR EXPLANATORY LANGUAGE
County to enter'upon the,above-mentioned property for '
i ctfon.purposes.
natur6 of:Permittee_.- Date