HomeMy Public PortalAbout6380 OAK AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION I CEA 81 8C(2-80) A P P L ICAT I O I4 FOR PERMIT
1 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 cer 7iedd�opy thereof(Sec.3800,La
Policy�No. 4-'0 Company- AZZ - 71
F1 Certified copy is hereby fur shed. I COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with the county building inspection p FOR APPLICANT TO FILL IN BUILDING
(PRINT OR TYPE ONLY) ADDRESS
Date pplicant�s.�d�� LOCALITY
i
CE TIFICATE OF EXEMPTION FROM 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. d
by the permit is for one hundred dollars ($100) or less.) U� DISTRICT NO. u PROCESSED BY V
1 certify that in the performance of the work for which this AIR HANDLING UNIT,CFM L^ v
permit is issued, 1 shall not employ any person in any manner L O
so as to become subject to the Workers'Compensation Laws. BOILER, BTU
APPROVALS DATE INSPECTOR'S SIGNATURE V
Date Applicant COMPRESSOR,BTU °�a ROUGH �(�-8 a
NOTICE TO APPLICANT: If, after making this Certificate of I VENTILATION SYSTEM 41
FINAL Q Z
Exemption, you should become subject to the Workers' /
Compensation provisions of the Labor Code, you must forth- If
EVAPORATIVE COOLER VALIDATION
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU VITY
LICENSED CONTRACTORS DECLARATION FLOOR: BTU D
I hereby affirm that I am licensed under provisions of Chapter HEATER: SUSPENDED UNIT
9 (commencing with Section 7000)of Division 3 of the Busi- WALL
ness and Professions Code, and my license is in full force and
effect. `A �
,
LiceDse NumberLic.Class-
i r
Contra or 941 Date �0 d
I am exempt from the licensing requirements as I am a ,
licensed architect or a registered professional engineer Plan check fee 25%of above.
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code). PERMIT ISSUING FEE$ v
Lic.or Reg.No. Date TOTAL FEE IY- I)
I
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT �,
I hereby affirm that I am exempt from the Contractor's NAME 4[,�v.„�
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): ADDRESS I
1, as owner of the property, will do the work and the r 1 0 n
structure is not intended or offered for sale (Section CITY TEL.NO. Coi {i0 0 0 0 0 ='
7044, Business and Professions Code). '
❑ OWNER
1, as owner of the property, am exclusively contracting o o
with licensed contractors to construct the project MAIL
(Section 7044,Business and Professions Code). ADDRESS r ?
CONSTRUCTION LENDING AGENCY CITY TEL.NO. ;
19'—
I hereby affirm that there is a construction lending agency CONTRACTOR
for the performance of the work for which this permit is ,
issued(Sec.3097,Civ.C.). T.
Lender's Name ADDRESS r
Lender's Address CITY TEL.NO.
I certify that I have read this application and state that the STATE LIC.
above information is correct.I agree to comply with all County LICENSE NO. CLASS G
ordinances and State laws regulating Heating, Ventilating and
Air Conditioning,and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
County to enter upon the above-mentioned pr eriy for
k19
n purposes. ti
7
nature of Permittee Date