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HomeMy Public PortalAbout5841 ROWLAND AVE_Mechanical__ o 4 I WORKL:Rb'COMPENSATION DECLARATION CEA 81 8C(2-80) •��P L QC AT�O YI 1 FOR PERMIT I hereby affirm that I have a certificate of consent to self insure, or a certificate of Workers'Compensation Insurance,or i HEATING-VE:NTILATI NG-AIR CONDITIONING a certified copy thereof(Sec.3800,Lab.C.) Policy No. Company f F1 Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY E• Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN BUILDING department. n y Date Applicant (PRINT OR TYPE ONLY) ADDRESS ed IAoV P .Qt LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE I _ J COMPENSATION INSURANCE NEAREST �C .�/ / (This section need not be completed if the work involved ABSORPTION UNIT,BTU CROSS ST. G j/ tL by the permit is for one hundred dollars ($100) or less.) DISTRICT NO. PROCESS)ID BY V I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM permit is issued. I sitall.not employ any person in any mannerr.�1 �r 1 ccO so as to become subject to the\k' rker� Compen tionn Law _ BOILER,BTU / ,�J APPROVALS DATE INSPECTOR'S SIGNATURE U �Date��Plicant �(/ COMPRESSOR,BTU ROUGH14 LU NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL `' Z Exemption, you should become subject to the Workers' 50 Compensation provisions of the Labor Code, you must forth- with comply with such provisions or this permit shall be EVAPORATIVE COOLER VALIDATION deemed revoked. LICENSED CONTRACTORS DECLARATION FURNACE:. FAU VI Y r ' FLOOR: BTU I hereby affirm that I am licensed under provisions of Chapter HEATER: SUSPENDED UNIT a ! 1<r 9 (commencing with Section 7000)of Division 3 of the Busi- WALL ness and Professions Code, and my license is in full force and ffect. u License Number,319�yI��—�Lic.Class`�-�7 �Q Q~7 Contractor. We! �r'l.,�a`te � I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer Plan check fee 25%of above. LAG acting in my professional capacity (Section 7051, Bus- iness and Professions Code). PERMIT ISSUING FEE$ t� Lic,or Reg.No. Date 4-21zTOTAL FEE Sd HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICAN I hereby affirm that I am exempt from- the Contractor's NAME License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): ADDRESS I, as owner of the property, will do the work and the TEL. NO. structure is not intended or offered for sale (Section CITY 7044, Business and Professions Code). ;�3 5 F 3 A ❑ OWNER le I, as owner of the property, am exclusively contracting 0,0 0 0 0 with licensed contractors to construct the project MAIL C// ©4 J/ ND (Section 7044,Business and Professions Code). ADDRESS 2'-,'o 4 8.5 0 CONSTRUCTION LENDING AGENCY CITY r le G 7 6 TEL.NO.,Z —11 0 0 0 4 5 0 � I ��.hereby affirm that there is a construction lending agency CONTRACTOR 5-1 6 A e S qt--Asso for the performance of the work for which this permit is issued(Sec.3097.Civ.C.). 4 0 71—8 2 Lender's Name ADDRESS -7�� Lender's Address kCITY 2e `E L.NO 1 certify that ve read this application and state that the ISTATE LIC. above infor ti to is correct.I agree to comply with all County LICENSE N ff—q ��,,� CLASS _ c` ordinanc alt tate laws re ulatittg Heating,Ventilating and-' Air Col it' ,inp and Itereb uthorire representatives of this SEE REVERSE FOR EXPLANATORY LA ACBE 7 Coun i o e er upon a ove-me ne roperty for I ins tion p poses. � I 1 I I tgn' ure of Permittee Date I I