HomeMy Public PortalAbout4819 WILLMONTE AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION 76A364C (�
I hereby affirm that I have a' certificate A consent to sell, CE-818 (2-80) APPLICATION F®R a®E u`s WT
insure, or a certificate of Workers'Compensation Insurance,0 1-IIEATING-VENTIL.ATI G-ABR CONDITIONING certified copy thereof(Sec.3800,Lab.C.)
Policy No. Company
❑ Certified copy is hereby furnished. . COUNTY OF LOS ANGELES BUILDING AND SAFETY
❑ Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN BUILDING /� /f/� "Ila./fa
ltlo-6
department. ADDRESS �7 �{' t/V�(1L,-F
Date Applicant (PRINT OR TYPE ONLY)
LOCALITY � "'
:4.. CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE '
COMPENSATION INSURANCE ' NEAREST
(This section need not be completed if the work. involved ABSORPTION UNIT,BTU CROSS ST. � � !I/� /�z•� O
-
by'the permit is for one hundred dollars ($100) oI less.) DISTRICT
i DISTRICT NO. PROCESSED BY (�
1 certify that in the performance of the work for which this AIR HANDLING UNIT,CFM O
permit is issued, I shall not employ any person in any manne
so as to become subject to the Workers'Compensation Laws! BOILER, BTU
I ® APPROVALS DATE INSPECTOR'S SIGNATURE lU
Date Applicant COMPRESSOR,BTU ✓ o�� �.
ROUGH
NOTICE TO APPLICANT: If, after making this Certificate of! VENTILATION SYSTEM � FINAL — Z
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth) EVAPORATIVE COOLER VALIDATION
with comply with such provisions or this permit shall b
deemed revoked. FURNACE: FAU A
LICENSED CONTRACTORS DECLARATION FLOOR: BTU
I hereby affirm'that I am licensed under provisions of Chapter HEATER: SUSPENDED UNIT
9'(commencing with Section 7000)of Division 3 of the Bust- WALL.
II ,
Mess and Professions Code, and my license is in full force and ,
'effect. I i
License Number, Lic.Class
Contractor Date
❑ I am exempt from the licensing requirements as I am'-a
licensed architect or a registered professional engine4r Plan check fee 25%of above.
acting in my professional capacity (Section 7051, Bu-
iness and Professions Code). PERMIT ISSUING FEE$
Lic.or Reg.No. Date TOTAL FEE
I
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
i
I hereby affirm that I am ,exempt from-the Contracto;'s NAME
License Law for the following reason (Section 7031.5, Btisi-
ness and Professions Code): ADDRESS •''7 2 G J A
101, as owner of the property, will do the worli and the.
structure is not'intended -or offered for sale (Section CITY TEL-.NO. �•
7044,Business and Professions Code). n'a 'o' Ari 0
F-1
OWNER Cr l t v ,,. .
I, as owner of the property, am exclusively contracting
,with licensed contractors to construct the proje t MAIL f� ` / c a'o ? °, v 0
(Section 7044,Business and Professions Code). l ADDRESS/7 vV -
CONSTRUCTION LENDING AGENCY. CITY T NO. 1, (:tr2 9'-8 Z
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit lis CONTRACTOR
issued SSec. 3097,Civ.C.). I
Lender s Name ADDRESS I'
Lender's Address I CITY TEL.NO.
I ,
1 certify that I have read this application and state that theSTATE LIC.
above information is correct.I.agree to comply with all Courity LICENSE NO. CLASS
ordinances and State•laws regulating Heating,Ventilating and
Air Conditioning,and Hereby authorize representatives of tis SEE REVERSE FOR EXPLANATORY LANGUAGE
County to enter upon th above-mentioned property for
inS Wurposes.
nature of Permittee Dae „-
- -