HomeMy Public PortalAbout6023 PRIMROSE AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION CEA 86 8 2-80) A i�P� C A T�®fes 1 FOR P E lid F��I �T
I hereby affirm that I have a' certificate of consent to self I �'!Y" U @71 U`C L�Ifs 0��
insure,or a certificate of Workers'Compensation Insurance,or I HEATING-VENTILATING-AIR CONDITION' UNG
a certified copy thereof(Sec.3800,Lab.C.)
Policy No. Company
Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING ARID SAFETY
Certified copy is filed with the county building inspection BUILDING ��j
department. FOR APPLICANT TO FILL IN ADDRESS �Y/f Y
Date Applicant (PRINT OR TYPE ONLY)
LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
COMPENSATION INSURANCE NEAREST
CROSS ST. j �j/ d
(This section need not be completed if the work involved ABSORPTION UNIT,BTU / ` �� O
by the permit is for one hundred dollars ($100) or less.) DISTRICT NO. PROCES D.BY IL)
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFMA51000, 0
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permit is issued, I shall not employ any person in any manner c i
so as to become subject to th rkers'C s ion BOILER,BTU
' APPROVALS DATE INSPECTOR'S.SIGNATURE LL
Date Applica COMPRESSOR,BTU N
ROUGH
NOTICE TO APPLICANT: If, after making this Certificate VENTILATION SYSTEM FINAL �'� — �► °- Z
Exemption, you should become subject to the Work
Compensation provisions of the Labor Code, you must fo EVAPORATIVE COOLER VALIDATION
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU. GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR: BTU
I hereby affirm that 1 amlicensed under provisions of Chapter HEATER: SW&PkNDED UNIT Q�
9 (commencing with Section 7000)of Division 3 of the Busi- ALL
ness and Professions Code, and my license is in full force and
effect.
License Number Lic.Cldss
Contractor Date
El I am exempt from the licensing requirements as I am a I
licensed architect or a registered professional engineer Plan check fee 25%of above.
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code). PERMIT ISSUING FEE$ (� Xv
Lic.or Reg.No. Date TOTAL FEE Q
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLIC T
I hereby affirm that I am exempt from- tfie Contractor's NAME
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): ADDRES
)(I, as owner of the.property, will do the work and the i TEL. NO
structure is not intended or offered for sale (Section CITYTe l / CP�J !Y
7044,Business and Professions Code). OWNER 2.2 8.6 A
❑
I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project MAIL �, # o o•o 0 o 8
(Section 7044,Business and Professions Code). ADDRESS
CONSTRUCTION LENDING AGENCY CITY II TEL.NO. yI 2 0 0 2 Q 5 O
I hereby affirm that there is a construction lending agency ® gyJ,a,/ ora o 2 Q 5 0 5
for the performance of the work for which this permit is CONTRACTOR
issued iSec.3097,Civ.C.). 0 5 2 7-8 3
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 I LICENSE NO. CLASS
ordinances and State laws regulating Heating,Ventilating and
Air Conditioning,and hereby authorize representatives of this I SEE REVERSE FOR EXPLANATORY LANGUAGE
County to ent&r upon the u entioned property for
pur os
1
Signature of Permittee ate