HomeMy Public PortalAbout5233 PAL MAL AVE_Mechanical__ WORKERit*COMPENSATION DECLARATION CEA slsClz_g0) APPLICATION FO R PERMIT
I herebye'affOR Oat L,ttave a' certificate of consent to self
insure, or 3.Wrtiffcate of Workers'Compensation Insurance,of HEATING-VENTILATING-AIR CONDITIONING
a,kertified copy thereof(Sec.3800,Lab.C.)
Policy No. Company COUNTY OF LOS ANGELES BUILDING AND SAFETY
El Certified copy is hereby furnished.
Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN BUILDING
department. ADDRESS T,),33
Date Applicant (PRINT OR TYPE ONLY)
LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
COMPENSATION INSURANCE I NEAREST }
(This section need not be completed if the work involved ABSORPTION UNIT,BTU CROSS ST. �lr 0
by the permit is for one hundred dollars ($100) or less.) DISTRICT NO. PROCE E av U
I Certify that in the performance of the work for which this AIR HANDLING UNIT,CFM 0�/ 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
APPROVALS DATE INSP CT R' IGNATURE W
Date Applicant i COMPRESSOR,BTU ROUGH y
'NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM _
I Exemption, you should become subject to the Workers' FINALmza��;
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDA ION
witli comply with such provisions or this permit shall be
deemed revoked. FURNACE: AUAVITY
LICENSED CONTRACTORS DECLARATION FLOOR:—BTU-1- I�(�
1 hereby affirm that I am licensed under provisions of Chapter r HEATER: SUSPENDED UNIT
9 (commencing with Section 7000)of Division 3 of the Busi- WALL
less and Professions Code, and my license is in full force and , Al 3 4 0 A
effect.
o 0,0 0 o s
License Number Lic.Class I o o 2 a 5 0
Contractor Date o o o 2 Q 5 0 6
1 am exempt from the licensing requirements as I am.a 1, 1 4—8 5
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).
Lic.or Reg.No. Date TOTAL FEE d o
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
I, as owner of the property, will do the work and the TEL.NO.
structure is not intended or offered for sale (Section CITY
7044, Business and Professions Code).
OWNER
I, as owner of the property, am exclusively contracting
Ahosq—
with licensed contractors to construct the project MAI L
(Section 7044,Bus"ess and Professions Code). ADDRESS
CONSTRUCTION LENDING AGENCY CITY TEL.NO.
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
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
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
rn pection purpos s.
. j 1
ignature of Permittee Date