HomeMy Public PortalAbout5508 ROBINHOOD AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION CEA 64C SO) APPLICATION FOR PERMIT
I hereby iVf trtu that I have certificate of consent to self
insure, or a certificate of Workers'Compensation Insurance,or HEATING-VENTILATING-AIR CONDITIONING
Polfftl N co y thereo Comps 800,LaE
!t 11M
Certified ropy 1n hereby furnished.
COUNTY OF LOS ANGELES 'BUILDING AND SAFETY
Certified copy Is filed with the county building inspection BUILDING a
di✓Jyn FOR APPLICANT TO FILL IN
Date ppllcant (PRINT OR TYPE ONLY) ADDRESS c� �,7
Olo
CF:'RTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE PR EQUIPMENT FEE LOCALITY T � r
COMPENSATION INSURANCE NEAREST p
(This section need not be completed .if the work involved ABSORPTION UNIT; BTU CROSS ST.
by the permit is for one huhdred dollm ($100) or lea.) DIarRICTNO. PRoctaas Y
1 certify that in the performance of the work for which this AIR HANDLING UNIT CFM / -0
permit is issued, 1.shall not employ any person In any manner �<</ �1 0
so as to become subject to the Workers' Compensation Laws. BOILER BTU
APPROVALS DATE INSp siC7NATURE
Date :Applicant COMPRESSOR BTU ROUGH A J LIJ�"
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEIM C�
Exemption, you should become subject to the Workers' FINAL T�
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIIJ ION
with comply with such provisions or this permtt &hall be
deemed revoked.
LICENSED CONTRACTORS DECLARATION FURNACE: FAU ITY ,
FLOOR: BTUI '
I hereby affirm that I arm licenced under provisions of Chapter HEATER: SUSPEN-DED UNIT
9 (commen-cing with Section 70005 of Division 3 of the Bual- WALL
nets and Professions Code, and my license Is in full force and
effect. �j ��
License Number Lic.Clan
Contractor 'Date
Eli am exempt from the licensing requirements as i am a '.
licensed architect or a registered profasyionai engineer Plan check fee 26%of above.
acting In my professional capaclty'(Section 7051, Bus-
iness and Professions Code). PERMIT ISSUING FEE a
Lic.or Reg.No. Data TOTAL FEE 5
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT # f1 6
I hereby aMm that I am exempt from- the Contractor's NAME ••• 4�7 5
License Law for the following reason (Section '7031:5, Bust-
ness and Professions Code): ADDRESS •;• * 42756 42756
1, as owner of the property, will do the work and the
structure Is not Intended or offered for salection CITY' TEL. NO.
�° 0221 =86
7044, 13uainea'end Profgaaipns Code).
OI,'as owner of the property, am exduslvely contracting 'OWNER
with licensed contractors to construct 'the project I MAIL ,tom '
(Section 7044, Business and Profesalons Code). ADDRESS JJ~
-CONSTRUCTION LENDING AGENCY CIT 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,CLy.C.). Ai
Lender s Name ADDRESS
Lender's Address CITY L.NO.
I certify that I have read this application end-state that the STATE LIC. -
above information Is correct. I agree to comply wtth all County EN E N CL
ordinances and State laws regulating Heating, Ventilating and
Air Conditioning, and hereby authorize re-prespntative-s of this SEE REVERSE FOR EXPLANATORY LANGUAGE x
County to enter upon the' aboyezmentioned property for
spectl�n ur set /
Sign ture of miltDate