HomeMy Public PortalAbout5214 PERSIMMON AVE_Mechanical__ V.oil KLRS'COMPENSArIONDLC'LARA1101, CEA 818(2-80) A,%PPLL=ICAT�ON FOR PERWT
I hereby affirm that I have a certificate of consent to self
ln•,urv. or a certificate of Workers'Compensation Insurvnee.(if I HEATING-VE:NTIL.ATIN -AIR CONDITIONING
a certified copy thereof'(Sec. 3800.Lab.C.)
Policv No. Company _
❑ Certified copy is hereby furnished. I COUNTY OF LOS ANGELES BUILDING AND SAFETY
❑ certified copy is filed with the county buildinr,inspection BUILDING ��(/
diP.11•tment. FOR APPLICANT TO FILL IN-7
',)ate Applicant (PRINT OR TYPE ONLY) ADDRESS
LOCALITY
CI RI'IFICATE OF EXEMPTION FROM WORKLRS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
COMPENSATION INSURANCE NEAREST }
'This section need not be completed if the work involved ABSORPTION UNIT, BTU GROSS ST. a0
ay the permit is for one hundred dollars (Slat)) or less.) I DISTRICT No PROCESS D eve V
I certif% that in the performiutce of the work for which this i AIR HANDLING UNIT,CFM pie y cc
pei mit i+ Issued. I shall not employ any person in am manner J r d O
,o as to become subject to th•W Iters Co I .ation La BOILER,BTU V
APPROVALS DATE INSPECTOR'S SIGNATURE
W
Date pplicant COMPRESSOR,BTU ROUGH i� N
VO'i1C' :T APPLICANT: If, after making this Cert' sate of I VENTILATION SYSTEM l+�
Pxemption, you should become subject to the Workers' �+b O FINAL 'r z
'llmpensutiy provisions of the Labor Code, you must forth- I EVAPORATIVE COOLER/ TSO � ,�e� - VALIDATION
,lith comply with such provisions or this permit shall be y^�• O DOd
seemed revoked. -
FURNACE: FAU I
LICENSED CONTRACTORS DECLARATION FLOOR*_ Q ligr
1 hereby affirm that I am licensed under provisions of Chapter HEATER: SUSPENDED UNIT
9 (commencing with Section 7000)of Division 3 of the Busi- I WALL
ness and Professions Code, and my license it in full force and
effect.
License Number Lie.Class
Contractor Date
❑ 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$ '7
Lie.or Reg.No. Date I TO AL EE s3
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
1 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 CITY L.NO.
structure is not intended or offered for sale (Section
7044, Business and Professions Code).
❑ I, as owner of the property, am exclusively contracting OWNER o 9 Q J`�1
with licensed contractors to construct the project MAIL
(Section 7044.Business and Professions Code). ADDRESS
I �
CONSTRUCTION LENDING AGENCY CITY TE O. p - . 3700
I hereby affirm that there is a construction lending agency --- —
for the performance of the work for which this permit is CONTRACT o r „ • `,
issued (Sec.3097,Civ.C.).
Lender's Name ADDRESS
Lender's Address CITY TEL.NO.
I certify that I hale read this application and ,tate that the STATE LIC.
aho%c information is correct.I agree to comply with all County LICENSE NO.&9710iff7k_ CLASS
ordinances and State laws regulating Heating, Ventilating and
Air Conditioning,and hereby authorise representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGh
Coun t nter pont to above-mentioned property for
inspec AUlaq "I
Sig ature o Permittee Date /