HomeMy Public PortalAbout6222 RENO AVE_Mechanical__ WRkERS„'COMPBNSATION DECLARATION 76A364C'- pp pp �p n�
Jhdieb a firm that I have a' cei;ificate of consent to self CE-818(2-80) A P P L��C 6=i T 0 O �1 FOR PER IMI T
y' f'
idsure,or a c@rtificate of Workers'Compensation Insurance,or HEATING-VENTILATING-AIR CONDITIONING
a vertified Copy th[Mef600ff(Sec.3800 Lab,C.)
Policy No.A4; / ompany ! s'
Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY '
Certified copy is riled with t county build' g' spect!on BUILDING
department. (�R�1 Z )/��
FOR APPLICANT TO FILL IN
Date Applicant / (PRINT OR TYPE ONLY) ADDRESS t O .
CERTIFICATE OF EXEMPTI N FRO ORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY
COMPENSATION INSURANCE NEAREST }
("this section need not be completed if the work involved ABSORPTION.UNIT, BTU CROSS ST. 0
by the permit is for one hundred dollars ($100) or less.) DISTRICT NO. PROCES ev (�
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM A
permit is issued, I shall not employ any person in any manner ( O
so as to become subject to the Workers'Compensation Laws. BOILER,BTU
APPROVALS DATE I P TOR' IGNATURE
Date Applicant COMPRESSORL!J
,BTU ROUGH; — N
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM Z
Exemption, you should become subject to the Workers' FINAL
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER
with comply with such,provisions or this permit shall be VALI TION
deemed revoked. FURNACE: FAU GRAVITY _
LICENSED CONTRACTORS DECLARATION FLOOR: BTU dfz6�
I.hereby affirm.that I am licensed under provisions of Chapter f HEATER: SUSPENDED UNIT
9 (commencing with Section 7000)of Division 3 of the•Susi- WALL
nese and Professions Code, and my license is in full force and
effect.
License Num er Lic.Class _ � 1.1 8, TA
Contractor
❑ I # o o ,0 0 0 8
I am a mpt fro he licensing requirements as:I am a
licensed architect or a registered professional engineer 'Plan check fee 25%of above.
acting in my professional capacity (Section. 7051, Bus-
iness and Professions Code). PERMIT ISSUING FEE$ , 0 0 2 Q 5 O
Lic.or Reg.No. Date TOTAL FEE d (�
HOME OWNER-BUILDER DECLARATION PLAN'CHECK.APPLICANT
0 0 0'2-(1500'
I hereby affirm that I am 'exempt from- the Contractor's NAME 2 b-8 4
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 TEL.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
with licensed contractors.to construct the project MAIL
(Section 7044,Business 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 tSec.3097,Civ.C.).
Lender s Name ADDRESS 9
Lender's Address
CITY TEL.NO.'�3
I certify that I have read this application and state that the
above information is correct.I agree to comply with all County LICENSE NO.,da
CLASS
ordinances and State laws regulating Heating, Ventilating and
Air Conditioning,and hereby authori representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
County to enter. upon the abov entioned properly for
inspection purposes.
Signature of ermittee Kate