HomeMy Public PortalAbout4847 WILLMONTE AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION CEA3B64$C(Z 801 fi I�P p- C A T�O p , O R '�E R I].G7 �`�
I hereby affirm that I have a' certificate of consent to self 11 F�1 Ir If'L� `�s i"� II II t7 II� LS Iff�S 1170
insure,or a certificate of Workers'Compensation Insurance,or J HEATING-VENTILATING-AIR CONDITIONING%
a certified copy thereof(Sec.3800,Lab C)
Policy No. Company rl
❑ Certified copy is hereby furnished. COUNTY OF LOS ANGELES ( BUILDING ARID SAFETY
❑ Certified copy is filed with the county building inspection } BUILDING
department. FOR APPLICANT TO FILL IN AODFtESS 10
'Date Applicant (PRINT OR TYPE ONLY)
• ' ' LOCALITY' q,L �.✓�(.;�,
CERTIFICATE OF'EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
COMPENSATION INSURANCE NE.ARES
(This section need not be completed if the work involved ABSORPTION UNIT, BTU CROSS 0
by the permit is for one hundred dollars ($100) or less.) DISTRICT NO. OCESSE v V
I certify that in the performance-of the work for which this AIR HANDLING UNIT,CFM '` lr
permit is issued, I shall.not employ any person in any manner S 6t7 0
so-as to become subject to.the Worke 'Compensation Laws.• BOILER, BTU
�/_ ,�/O•� `.�-/1,�� -� C APPROVALS DATE INSPECTOR'S SIGNATURE
e//J`✓�///o
Applicant i =ii COMPRESSOR,BTU ROUGH '' W
N
NOTICE TO APPLICANT: If, after making this Certificate of I VENTILATION SYSTEM Z
Exemption, you should become subject to the Workers' FINAL —
Compensation provisions of the Labor Code, you must forth-
EVAPORATIVE COOLEVALIDATION
with comply .with such provisions or this permit shall be '
deemed revoked. FURNACE: FAU
LICENSED CONTRACTORS DECLARATION FLOOR: BTU
I hereby affirm that I am licensed under provisions of•Chapier HEATER: SUSPENDED UNIT ®�
9 (commencing with-Section 7000)of Division 3 of the Busi- } WALL•
ness and Professions Code, and my license is in full force and "
effect.
License
r
License Numb6f-!'24/4-Lic.Class 2aO
i
44rq�ez—; ,
❑ I am exempt'from the licensing requirements as I-am a
licensed architect or a registered professional engineer I' Plan check fee 25%of above,
acting in my professional capacity (Section 7051, Bus- (, PERMIT ISSUING FEE$
iness and Professions Code).
Lic,or Reg.No. Date I, TOTAL FEE SV
HOME OWNER-BUILDER DECLARATION OLAN'svECK APPL-I IVT
'I hereby affirm that I am exempt from--the Contractor's NAME
• License Law for the following reason (Section 7031.5, Busi-
oess and Professions Code): I, ADDRESS
❑ I, as owner of the property, will do the work and the CITY TEL.NO.
structure is not intended or. offered for sale (Section r i
7044,Business and Professions Code).
OWNER 12•4 5 3 3 A
❑ I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project MAIL 7 #1010"0 0 0 8
(Section 7044,Business and Professions Code). l ADDRESS /.t G
11
CONSTRUCTION LENDING.AGENCY
IJ CITY7C . TEL �' p i ,2 0`0 3850
I hereby affirm that there is a construction lending agency I I o o to _
for the performance of the work for which this permit is CONTRACTOR 3 8 5 0 v
issued�Sec..3097,Civ.C.).
Lenders Name ADDRESS 10 c,2 3 $2:
Lender's Address P��
TEL.Ng� a_50 19
I certify-that I have read this application and state that the I rf LIC.
above information is correct.I,agree to comply with all County. ,IE NO .G CLASS G ZQ-
ordinances and State laws regulating Heating, Ventilating and i
Air Conditioning,and hereby authorize representatives of this I SEE REVERSE FOR EXPLANATORY LANGUAGE
County to enter upon the above-mention d property for
L
gnature of Permittee date