HomeMy Public PortalAbout6384 OAK AVE_Mechanical__ AWOR1.'t}I?•S'COMPENSATION DECLARATION I CE86 8(2-80) L����� ®n�I FOR C I>— Y F7[t��
I hereby affirm that 1 have a' certificate of consent to self !
insure, or a certificate of Workers'Compensation insurance,or HEATING-VENTILATING-AIR CONDITIONING
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a certifiedcopythereof(Sec.3800,La
Policy`i4d'"" 6'3(j Compan
Certified copy is hereby furnished. COUNTY OF LOS ANGELESBUILDING ARID SAFETY
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Certified copy is filed with the county building inspection BUILDING
� • , FOR APPLICANT TO FILL IRI
Date
.9 (PRINT���-� I - ��9 (PRINT OR TYPE ONLY) ADDRESS
�' LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
COMPENSATION INSURANCE NEAREST CROSS ST. c2A�� d
( This section need not be completed if the work involved ABSORPTION UNIT,BTU O
by the permit is for one hundred dollars (5100) or less.) n/� yy 'l DISTRICT NO. PROCES D ev U
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM k&n ✓ V �+� W
permit is issued, I shall not employ any person in any manner O
so as to become subject to the Workers' Compensation Laws. BOILER,BTU H
n APPROVALS DATE INSPECTOR'S SIGNATURE W
Date Applicant COMPRESSOR,BTU fJ ROUGH •�P - � F (rte a.� N
NOTICE_TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEMFINAL - .e 2
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION
with comply with such provisions or this permit shall be
deemed revoked.
FURNACE: FAUR VIT
LICENSED CONTRACTORS DECLARATION FLOOR: BTU
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
mess and Professions Code, and my license is in full force and t `/
effect.
License Numberyy� V Lic.Class �~
Contracto % ,Dates l22—
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 my professional capacity (Section 7051, Bus-
iness and Professions Code). PERMIT ISSUING FEE$
Lic.or Reg.No. Date I TOTAL FEES s()
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 Code): ADDRESS — 46
v.Q iI
I, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section CITY TEL.NO. j D o 0 o D r
7044.Business and Professions Code).
❑ OWNER : o'o ((3 5 0
I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project MAIL T
(Section 7044, Business and Professions Code). ADDRESS r. o o
r
GONSTRUCTION LENDING AGENCY CITY TEL.NO. (� � 1 y— f
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is CONTRACTOR '
issued(Sec.3097,Civ.C.).
Lender's Name ADDRESS '
ofi
Lender's Address CITY TEL.NO. _
1 certifythat i have read this application and state that the
PP STATE ' ,et LIC.
above information is correct.I agree to comply with all County LICENSE NO. J Q CC SS
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 property for
a
illspe n purposes.
.Signature of Permittee Dat