HomeMy Public PortalAbout5755 RIO HONDO AVE_Mechanical__ 76A364
WRIKERS'COMPENSATION D1:CLARATION I, CE-B18C(2-80) IL0�F�l�0®1�I ®� IMI 0�
ffirmthat 1, have a' certificateofonsentto self
Prar.5VrkersCompensationInsurance,or HEATING-VENTILATING-AIR CONDITIONING
opy tnereof(Sec.3800,Lab.C.)
Policy No. Company
Certified copy is hereby furnished.
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with the county building inspection FBUILDING
OR APPLICANT TO FILL IN F-'
department. St.,
Date Applicant (PRINT OR TYPE ONLY) LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' LOCALITY G
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
COMPENSATION INSURANCE NEAREST }
(This section need not be completed if the work involved ABSORPTION UNIT, BTU CROSS ST. a0
by the permit is for one hundred dollars (5100) or less.) DISTRICT NO. PROCESSED 0
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 manner O
so as to become subject to the Workers' Compensation Laws. BOILER, BTU I—
t APPROVALS DATE INSP T*ATUREtU
DayApplicant_- �{�d COMPRESSOR,BTU�� �� O v ROUGH
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL 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
deemedrevoked. FURNACE: FAU 13A ITY
LICENSED CONTRACTORS DECLARATION FLOOR: BTU
I hereby affirm that I am licensed under provisions of Chapter HEATER: SUSPENDED UNIT
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. ���JJ���� ��ff����
License Numbe;223 7�' �,�-�Liic..Class e, 2-0 r 3 o% 1 3.91 R
Co 0
Ce
El tlam exempt from the licensing requirements as I am a - I ° o 3 Q 5 0
licensed architect or a registered professional engineer Plan check fee 25%of above.
acting in my professional capacity (Section 7051, Bus- o o - .31250'
iness and Professions Code). PERMIT ISSUING FEE $ S 0 1.22-850
.22-85
Lic.or Reg.No. Date TOTAL FEE
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that 1 am exempt from- the Contractor's NAME
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): ADDRESS
❑ 1, as owner of the property, will do the work and the 7
structure is not intended or offered for sale (Section CITY TEL.
7044, Business and Professions Code).
E] OWNER
I, as owner of the property, am exclusively contracting
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 CONTRACTOR
for the performance of the work for which this permit is
issued .Sec. 3097,Civ.C.).
Lender.s Name ADDRESS
Lender's Address CITY TEL.Na�/ aL�l�
I certify that I have read this application and state that the A LIC.
above information is correct.I agree to comply with all CountyLICENSE NO. CLASS f-40
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 property for
inspectio p trpq es.
Signature of Permittee Date