HomeMy Public PortalAbout5022 RIO HONDO AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION CEA 816C(2-BO) l!� 0���8®I�I, ®� u�8
I hereby affirm.rthat I have a' certificate of consent-to self
insure,ora ctrtihoz�ipj3f Workers'Compensation Insurance,or. p-IEAVING_VE NTIL.ATING_AIIR CONDITIONING
a certified copy thereof(Sec.3800,Lab.C.) V
Policy No. Company , J
❑ Certified copy is hereby furnished. I ' COUNTY OF LOS ANGELES I BUILDING ARID SAFETY
! j i
Certified copy is filed with the county building inspection
❑ FOR APPLICANT TO.FILL IN BUILDING
department. I ADDRESS ,t aa #0AA
Date Applicant # (PRINT OR TYPE ONLY)
LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' ' • NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
COMPENSATION INSURANCE '` ' NEAREST f�-usa
' t• CROSS ST. }
(This,section need not be. completed if the work involved ABSORPTION UNIT,BTU a
by the permit is for one hundred dollars ($100) or less.) DISTRICT NO. P c BED BY V
I certify that in the performance of the.work for which this AIR HANDLING UNIT,CFM /� �(
permit is issued, I shall not employ any person in any anner 1 U o
so as to become subject to the Work pensa Laws. ! BOILER,BTU
/� t APPROVALS '7DATE IN PE OR'S SIGNATURE
,Date t 9pplicant s Il- COMPRESSOR,BTU `' ROUGH 'C.'� a
NOTICE TO PPLICANT: If, after aking this Certificate of" :3 { VENTILATION SYSTEM FINAL Z
Exemption, you should become subject to the Workers',': 6 t
Compensation provisions of the Labor Code, you must forth,;': EVAPORATIVE COOLE r V I_ Ae :ON,s
with comply with such provisions or this permit shall be'.. ; 4
deemed revoked. FURNACE: FAU GRAVITY
(J�
LICENSED CONTRACTORS DECLARATION FLOOR: BTU' '_ '
I hereby affirm that I am licensed under provisions of Chapfec:~.-I
HEATER: SUSPENDED UNIT
9 (commencing with Section 7000)of Division 3 of the Busi ,. WALL
nese and Professions Code, and my license is in full force`nnd, / 751,r -+— d _ - '•-`
effect. . —
License Number Lic.Class
Contractor Date
❑ Y
I am•exempt from the licensing requirements as I am a ' _
licensed architect'or a'•registered professional engineer Plan check fee 25%Of above. ; __—'SI'l ) ;:`.L!?,
acting in my profession$$ capacity (Section 7051, Bus-' O 50 I '
mess and Professions Code). PERMIT ISSUING FEE $ v ; A;K,1 D3
Lic.or Reg.No. Date TOTAL FEE + X0.00 A32.ZS
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that•I am•exempt from- the'Contractor's NAME C
License Law for the following reason (Section 7031.5, Busi- f n'^
ess nd Professions Code): •ADDRESS �V o�a P 'o •7-
as owner of the property, will do the work and the r TEL. NO. L !
CITY ,�f S
structure is not intended or offered'for sale (Section f
7044,Business and Professions-Code). r
0 OWNER f 7I I T/ 10 , 6b,
I, as owner of the property, am exclusively contracting. j
with licensed contractors to construct' the project MA1,L• /�
(Section 7044,Business and Professions Code). ADDRESS -CA
TEL.NO.
CITY I ( A r�
CONSTRUCTION LENDING AGENCY t" LJ• Vx
Ihereby affirm that there is a construction lending agency I'•• �
for the. performance of the work.for which this permit is CONTRACTOR
' iJ'.'e
ued(Sec.3097,Civ.`C.).' LL Di
nder's Name. tADORESS
r..'.
nder's Address �j�Y Sa TEL'.NO.
certify that I have read this application and state that the STATE LIC.
ove information is correct.I agree to comply with all County LICENSE NO. CLASS
dinances and State laws regulating Heating;Ventilating.and )-
r Conditioning,and hereby authorize•representatives of this SEE,REVERSE FOR EXPLANATORY LANGUAGEunty to enter upon the abo e-mentioned property for ctio s.
Signature of mittee ate