HomeMy Public PortalAbout6040 ROWLAND AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION CEA 818 C(2-BO) A P P L� CAT 0®1�l FOR P E R IIV'll T
I hereby affirm that I have a' certificate of consent to self
insure,or a certificate of Workers'Compensation Insurance,o'r HEATING-VENTILATING-AIR CONDITIONING
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a certified copy thereof(Sec.3800,Lab.C.)
Policy No. Company. +
Certified copy is hereby furnished. COUNTY OF LOS ANGELES �' BUILDING AND SAFETY
I
Certified copy is filed with the county building inspection BUILDING
FOR APPLICANT TO FILL IN
department. I ADDRESS
Date Applicant (PRINT OR TYPE ONLY)
LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEEIC
COMPENSATION INSURANCE NEAREST
(This section need not be completed if the work involved ABSORPTION UNIT, BTU CROSS ST. ��„y O
by the permit is for one hundred dollars ($100) or less.) DISTRICT NO. PROCESSED BY 0
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM fly
permit is issued, I shall not employ any person in any manner S1 O
so as to become subject to the ers'Compen i Laws. BOILER,BTU
O APPROVALS DATE. INSPECTOR'S SIGNATURE
DaApplicant COMPRESSOR,BTUy N
ROUGH
NOTICE TO APPLICANT: f, after making this Certificate of Z VENTILATION SYSTEM FINAL
r — Z
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLERVALIDATION
with comply with such provisions or this permit shall be ///� ♦�
deemed revoked. FURNACE: FAU GRAVITY—
LICENSED
RAVITY LICENSED CONTRACTORS DECLARATION FLOOR: BTU
I hereby affirm that I am licensed under provisions of Chapter HEATER: SUSPEND D UNIT
9 (commencing with Section 7000)of Division 3 of the Busi- WALL ooF
ness and Professions Code, and my license is in full force and
• effect. �75 J��
License Number 7 Lic.Class '
Contracto Date ff::24 -P U
I am exempt from the licensing requirements as I an 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$1 0 166 4 7 4,3 A
Lie.or Reg.No. Date TOTAL.FEE Q
I'f'o 0 0 0 0
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
2 20,50
I hereby affirm that I am exempt from- the Contractor's NAME 2' •
License Law for the following reason (Section 7031.5, Bus!- C c c 2 0,5 C E
ness and Professions Code): ADDRESS. /7-1
I, as owner of the property, will do the work and the CITY 0 R 2 4—8 3.
structure is not intended or offered for sale (Section TEL. NO 3
7044,Business and Professions Code).
❑ 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 G /,0_,gZ
,
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.NO. _3 g
1 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. Sl�(� CLASS fr
ordinances and State laws gulating Heating,Ventilating and
Air C itioning,and lie y authorize representatives of this I SEE REVERSE FOR EXPLANATORY LANGUAGE
Cc ty to enter up a ab e-mentioned property for
it a ion purposes.
Signature of Permittee Date l