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HomeMy Public PortalAbout5350 PERSIMMON AVE_Mechanical__ WORKERS'COMPENSATION DECLARATIODO, I yCZ 80 8 112-80) A P P U`>es A V O N FOR PER ugh T I hereby apfficm that I have W certificate of consent to self Ik. insure, or a certificate of Workers'Compensation Insurance,or HEATING-VENTILATING-AIR CONDITIONING a certified copy thereof(Sec.3800,Lab.C.) _ Policy No. �` .L 6"Snv Ihl !, Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN BUILDING Ce Datedepa e ; pplicant ®,V%C_V-,9_. �Sr;�`�eSI I (PRINT OR TYPE ONLY) ADDRESS LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE COMPENSATION INSURANCE t NEAREST CROSS ST. C- d (This section need not be completed if the work involved ABSORPTION UNIT,BTU O by the permit is for one hundred dollars ($100) or less.) DISTRICT NO. PROCESS 6Y V I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM /p permit is issued, I shall not employ any person in any mannerE �57 (,J� O~ so as to become subject to the Workers'Compensation Laws. BOILER, BTU U APPROVALS DATE INSPECTOR'S SIGNATURE Date Applicant COMPRESSOR,BTUW ROUGH N NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL•' I �� z Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION with comply with such provisions or this permit shall be oe deemed revoked. FURNACE: FAUB14 TU GRAVITY LICENSED CONTRACTORS DECLARATION /CI I hereby affirm that I am licensed under provisions of Chapter HEATER: SUSPENDED UNIT 1 9 (commencing with Section 7000)of Division 3 of the Busi- WALL ness and Professions Code, and my license is in full force and effect. ' e�/-� License Number ■���7Q�5^.�5�2 Lic.Class- C/ —r�`� Contractor 4���C►anN�.JGI1C�jbate If 0 1 8-1 I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer i Plan check fee 25%of above. acting in my professional capacity (Section 7051, Bus- iness and Professions Code). PERMIT ISSUING FEE$ Lic.or Reg.No. Date TOTAL FEE HOME OWNER-BUILDER DECLARATION. PLAN CHECK APPLICANT I hereby affirm that I am exempt from-the Contractor'sI NAME License Law for the following reason (Section 7031.5, Busi- z,71 0 8 A ness and Professions Code): ADDRESS 1, as owner of the property, will do the work and the I CITY # o o io 0 o 8 structure is not intended or offered for sale Section + TEL.NO. 7044, Business and Professions Code).❑ OWNER 2'o'0'6 8.5 0 I, as owner of the property, am exclusively contracting y with licensed contractors to construct the project MAIL ae o 0 0 6 8.5 0-6:(Section 7044,Business and Professions Code). ADDRESS Y • CITY* TEL.NO. 1 0.2 5—8 2 CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency CONTRACTOR for the performance of the work for which this permit is issued SSec. 3097,Civ.C.). Lenders Name ADDRESS ©6 Lender's Address CITY TEL.NO. (Zg —0 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. V 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 properly for inspection purposes. p ry� Signature of Permittee Date f _