HomeMy Public PortalAbout5241 PAL MAL AVE_Mechanical__ WORKERS COMPLNSATION DECLARATION 76A364C
I herereby a717cm that I have a certifu ate of consent to =elf CE 818 (2 Bo) APPLICATION FOR PERMIT
msnre4ur a certificate of Workers Compensation Insurance or HEATING-VENTILATING-AIR CONDITIONING
a certified copy thereof(Sec 3800 Lab C )
Policy No Company
❑ Certified copy is hertby furnished COUNTY OF LOS ANGELES BUILDING AND SAFETY
Cert❑ depalfied rtment cop) n fled with the county buildingmspetnon FOR APPLICANT TO FILL IN ADDRESS
Date Applicant (PRINT OR TYPE ONLY)
LOC ALITV
CF RTIFICATE OI EXEMPTION FROM WORKERS NO TYPE OF APPLIANCE OR EQUIPMENT FEE '
COMPENSATION INSURANCE NEARESTCROSS ST �'(�.(/(/ d
(This section need not be Completed if the work involved ABSORPTION UNIT BTU
by the perml[ is for one hundred dollars (5100) or less) DISTmcT No vaOCEssEo e
I lertif) that in thL performance of the work for which this AIR HANDLING UNIT CFM-
permit
FM permit is issued I shall not employ any person In any manner Oa O
so as to become subject to the Workers Compensation Laws BOILER BTU UUUF
APPROVALS DATE IN +E ,OAS SNATU E yyW
Date Applicant COMPRESSOR BTU ROUGH r (q
NOTICI, TO APPLICANT If after making this Certificate of VENTILATION SYSTEM FINAL ?
Exemption you should become subject to the Workers
Compensation provisions of thL Labor Code, you must forth EVAPORATIVE COOLER VALIDATION
with comply with such provisions or this permit shall be
deemed revoked
FURNACE EAU- GRAVITY_
LICFNSFD CONTRACTORS DECLARATION FLOOR BTU
-
I hereby affirm that I am licensed under provisions of Chapter HEATER SUSPENDED UNIT
9 (commencing with Section 7000) of Dntsion 3 of the Bust WALL ��/-, {/��[/�/��� 1 e3 8,0 Q
Less and Professions Code and my license u m full forte and f ��//
effect # • • • • • 8
License Number Lic Class
I • • 2050
Contractor Date 0 - 020505
❑ 1 am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer Plan check fee 25%of above 01 18-85
aetrng In my professional capacity (Section 7051 Bus
loess and Professions Code) PERMIT ISSUING FEES U SQ
Lm or Reg No Date TOTAL FEE
HOME OWNLR BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractors NAME
License Law for the following reason (Section 7031 5 Busi
ness and Professions Code) ADDRESS
12 1 as owner of the property will do the work and the
structure a not intended or offered for sale (Section CITY TEL NO
7044 Business and Professions Code)
OWNER
❑
1, as owner of the property am exclusively contracting I"I IV��Q rn
with licensed contractors to construct tht project MAIL p
(Section 7044 Business and Professions Code) ADDRESS .Z / M Y 0.1 AA 4
CONSTRUCTION LLNDING AGLNCY CITY�� TEL NO Vq3 Sys 6
I hereby affirm that there Is a construction lending agency _ 11✓✓ J
for tht performance of the work for which this permit is CONTRAC OR
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 1 agree to compl) with all County LICENSE NO CLASS
ordinances and State laws regulating Heating Ventilating and lli�
Air Conditioning and hereby authorile Tepresentmnes of this SEF REVERSE FOR }XPLANATORY LANOUA(,F
County to enter upon the above mentionLd property for
wspy�tm�ores
Signature of Perm t c F`�eD e