HomeMy Public PortalAbout5715 ROWLAND AVE_Mechanical__ WORKERrCOM ENSRTION DECLARATION EA gs8C
C (2-80) APPLICATION FOR PERMIT
I hereby affirm a'
certificate of consent to self
insure,or a certificate of Workers'Compensation Insurance,or HEATING-VENTILATING-AIR CONDITIONING
a certified copy thereof(Sec.3800,Lab.C.)
Policy No. Company COUNTY OF LOS ANGELES BUILDING ARID SAFETY
C1 Certified copy is hereby furnished.
Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN BUILDING
department. �s
Date Applicant (PRINT OR TYPE ONLY) ADDRESSOeW
LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
COMPENSATION INSURANCE NEAREST /j ^
(This section need not be cpmpleted if the work involved ABSORPTION UNIT,BTU CROSS ST. U� /7�(� d
by the permit is for one hundred dollars ($100) or less.) DISTRICT NO.. PRO D BY V
1 certify that in the performance of the work for which this AIR HANDLINb UNIT,CFM
permit is issued, I shall not employ any person in any manner O
so as to become subject to the Workers' Compensation Laws. BOILER, BTU
APPROVALS DATE INSPECTOR'S SIGNATURE
Date ApplicantW
COMPRESSOR,BTU N
ROUGH
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM Q, Z
Exemption, you should become subject to the Workers' FINAL
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR: BTU
I hereby affirm that I am'licensed under provisions of Chapter HEATER: SUSPENDED UNIT
9 (commencing with Section 7000)of Division 3 of the Busi= ' WALL
ness and Professions Code, and my license is in full force and
effect. C014-//16
License Number Lic.Class
Contractor Date — AM44 Agra.
I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer Plan check fee 25%of above.
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code). PERMIT ISSUING FEE$
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-
nes and Professions Code). ADDRESS 9 5'5 9 0 A
i
z;I, as owner of the property, will do the work and the #V. 0 0o 8
structure is not intended or offered for sale (Section CITY TEL.NO.
7044,Business and Professions Code).
OWNER�/j/t �/ / aiPf1 2 ° ° 1 -6.50
OI, as owner of the property, am exclusively contracting
with licensed contractors to construct the project MAIL /' o o ° 1'6 5 0 U
(Section 7044,Business and Professions Code). ADDRESS.?
NO. 08 1 2,-8 2
CONSTRUCTION LENDING AGENCY
( CITY TEL.� UJ Cif ��
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.NO.
I certify that I have read this application and state that the STATE LIC.
above information is correct.I agree to comply with all County LICENSE NO. CLASS
ordinances and State laws regulating Heating, Ventilating and
Air Conditioning, and eby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
County enter o the above-mentioned property for
,,is
9;;purpos
Sig ature of Permittee Date