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HomeMy Public PortalAbout10232 OLIVE ST_Mechanical__ WORKERS'COMPENSATION DECLARATION CEA 818C(2-BO) AkP P LL C A Il 0 O "FOR R P E {R W T 1 hereby affirm_that I have a' certificate of consent to self insure, or a certificate of Workers'Compensation Insurance,of I HEATING-VENTILATING-AI CONDITIONING a certified copy thereof(Sec.3800,Lab.C.) �� r.. lrilicy No. Company Certified copy is hereby furnished. COUNTY OF LOS ANGELES r r BUILDING AND SAFETY Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN BUILDING department. 'ADDRESS d Date Applicant (PRINT OR TYPE ONLY) ` LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS', NEAREST NO. TYPE OF APPLIANCE OR EQUIPMENT FEE M1 COMPENSATION INSURANCE CROSS ST. y{o�/ d (This section need not be completed if the work involved ABSORPTION UNIT, BTU O by the permit is for one hundred dollars ($100) or less.) DISTRICT NO. r� PROCESSED v V I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM s'p y cc permit is issued, I shell not employ any person in any manner o;**' O so as to become subject to Workers'Co nsatio Laws, BOILER,BTU � 0 APPROVALS DATE INSPECTOR'S SIGNATURE (~j ,l„�,� _ W .� _ Dat ��Z��Applicant COMPRESSOR,BTU ROUGH N NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL %RaVJR � Z 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: FAU GRAVITY LICENSED CONTRACTORS DECLARATION FLOOR: BTU I hereby affirm that I am licensed under provisions of Chapter I HEATER: SUSPENDED UNIT A?, r 9 (commencing with Section 7000)of Division 3 of the Busi- WALL �Ss'� ?� ness and Professions Code, and my license is in full force.and effect. _ .J License Num er ©� Lie.Class w 1 Contract Date_ 5 QZ" i+ 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- 1 iness and Professions Code). If PERMIT ISSUING FEE$1 A v Lie,or Reg.:No. Date I TOTAL FEE L30 �? HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT I hereby affirm that I am exempt from-the Contractor's Ii NAME License Law for the following reason (Section 7031.5, Busi- 1 9 1.5 A ness and Professions Code): ADDRESS 1, as owner of the property, will do the work and the TEL.NO CITY . structure is not intended or offered for sale (Section I 7044,Business and Professions Code). ❑ OWNER 2 o - 30.50 I, as owner of the property, am exclusively contracting �� a .c 0 J C !. with licensed contractors to construct the project q MAIL (Section 7044,Business and Professions Code). ++ ADDRESS Q� �� 64 v 7C.. CSI 2—8 v CONSTRUCTION LENDING AGENCY 1 CITY TEL NO.kr1J _Z; I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is CONTRACTOR t.. issuedSec.3097,Civ.C.). Lender s Name ADDRESS 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. t:33 CLASS ordinances and State laws regulating'Heating,Ventilating and Air Conditioning,and hereby authorize representatives of this SEE REVERSE FOR EXPLANA'T'ORY LANGUAGE unty to enter upon the above-mentioned property for ns ection p re ' oJ�fje I cvy Signature of Permittee Date - 9