HomeMy Public PortalAbout4905 ROBINHOOD AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION ' CEA 86 8C(2-80) A P P UC A T�®N KO R PER IMF T
I hereby affirm that I have a' certificate of consent to self
insure, or a certificate of Workers'Compensation Insurance,or I HEATING-VENTILATING-AIR NTILATING-AIR CONDITIONING
a c�rtfffe�„co p herGp�(Sec.3800,L
Policy N/�,� Comp COUNTY
COUNTY OF LOS ANGELES ��� BUILDING ARID SAFETY
Certified copy is hereby furnished.
Certified copy fs flied with the county bu' ing inspection FOR APPLICANT TO FILL IN BUILDING t
d ar ADDRESS a5
Date Applicant FAIR
(PRINT OR TYPE ONLY)
LOCALITY
C'RT FICATE OF EXEMPON ROM WORKERS' TYPE OF APPLIANCE OR EQUIPMENT FEECOMPENSATION INSURANCE NEAREST(This section need not be completed if the work involvedABSORPTION UNIT, BTU CROSS ST. 0by the permit is for one hundred dollars ($100) or less.) DISTRICT NO. PROCES aY o VI certify that in the performance of the work for which.this HANDLING UNIT,CFM s `,b` cc
permit is issued, I shall not employ any person in any manner rj � V v 0
so as to become subject to the Workers'Compensation Laws. BOILER.,BTUti
APPROVALS DATE I INSPECTOR'S SIGNATURE W
Date Applicant COMPRESSOR,BTU ROUGH y
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM Z
Exemption, you should become subject to the Workers' FINAL
Compensation provisions of the Labor Code,you must forth- EVAPORATIVE COOLER /� VALIDATION
with comply with such provisions or this permit shall be SiCC
deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR: BTU
1 hereby affirm that I am licensed under provisions of Chapter HEATER: SUSPENDED UNIT
9 (commencing with Section 7000)of Division 3 of the Busi- WALL
ness and Professions Code, and my license is in full force and
effect. /
License Numb. �� Sl.ic.Class
Contractor w Date
F1 I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer Plan Check fee 25%of above.
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code). PERMIT ISSUING FEE$ O
Lic.or Reg.No. Date TOTAL FEE -
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from-the Contractor's . NAME
License Law for the following reason (Section 7031.5, Busi- AI
�_ 3 4 2 5 A
ness and Professions Code): ADDRES a'� ��
❑ I, as owner of the property, will do the work and the ,p '� ° o c o o 8
TEL.NO
structure is not intended or offered for sale (Section CITY 4 g!
7.044,Business and Professions Code), OWNER
I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project . MAIL •° ° ° 3 Q,5 O 5
(Section 7044,Business and Professions Code). ADDRESS d S r
CONSTRUCTION LENDING AGENCY CITY�_ TEL.NO. 3 07,06-83
I hereby affirm that there is a construction lending agency CONTRACT R Y ��
for the performance of the work for which this permit is
issued(Sec.3097,Civ.C.).
Lender's Name ADDRESS° V �
Lender's Address CITY n TEL.NO.�9
I certify that I have read this application and state that the STATEAA LIC.
above.fnformation is correct.I agree to comply with all County LICENSE NO Q T CLASS
ordinances and State laws regulating Heating, Ventilating and
Air Conditioning,and hereby authorize representatives of this SEG REVERSE FOR EXPLANATORY LANGUAGE
Cou to enter upon the rbove-mentioned property for
insp n purposes.
Z S
ig turq In 6 I,ttee Date