HomeMy Public PortalAbout4928 WILLMONTE AVE_Mechanical__ WORK]: S'COMPENSATION DECLARATION 76A364C I�p �a �p nn
i• CE-818,(2-80) APIrLL,�`�sAT0®u� FOR PER0�'u0T
I hereby affirm that I have a° certificate of consent to self 1
insure, or a certificate of Workers'Compensation Insurance,or HEATING-VENTILATING-AIR CONDITIONING
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a certified c rrfat' /pec.3800 VA
Policy No.� J�Pmpany E///Y /� 7 C,
Certified copy is hereby furnished. ?NO.
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with th oun uilding in cti BUILDINGOd artment. FOR APPLICANT TO FILL IN ADDRESSoDate_��pplican (PRINT OR TYPE ONLY) LOCALITYCERTIFICATE OF EXEMPTION FROM WORKERS' TYPE OF APPLIANCE OR EQUIPMENT FEE
COMPENSATION INSURANCE NEAREST }
(This section need not 'be completed if the work involved ABSORPTION UNIT, BTuCROSS ST, tl
by the permit,is for one'hundred dollars ($100) or less.) DISTRICT NO. PROCES ED BY U
1 certify that in the performance.of the work for which this AIR HANDLING UNIT,CFM �` r/ cc
permit is issued, I shall not employ any person in any manner ' Q 0
so as to become subject to the Workers'Compensation Laws. BOILER, BTU
APPROVALS DATE INSPECTOR'S SIGNATURE W
Date ApplicantCOMPRESSOR,BTU ROUGHV)
NOTICE TO APPLICANT: If, after.making this Certificate of VENTILATION SYSTEM ` 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: pAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR: BTU 7 7
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 �Q D d
effect. �j �q r
License Numbe v ' ic.C1ass.S` a
Contractor Date
Ism 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).
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- Y
ness and Professions Code): ADDRESS ®
I, as.owner of the property, will do the work(Section
the CITY EL.NO
structure,is not intended or offered for sale Section 0 4 2'7 OWNA.
O
7044,Business and Professions Code). - -
ER /�-
I, as owner of the property, am exclusively,contracting # o'o 0 0 0 8•
with licensed contractors to construct the project MAIL
(Section 7044,Business and Professions Code). ADDRESS—Z gF 27,00-
CITY L.NO.
CONSTRUCTION LENDING AGENCY I 2 7 0 0 v 0 0 0
I hereby affirm that there is a construction lending agency CONTRACTOR �� /act
07.21
for the performance of the work for which this permit is
issued(Sec.3097,Civ.C.). ..-81 '
Lender's Name ` ADDRESS
Lender's AddressCITY TEL.NO.
I certify that I have read this application and statethat the STATE �y1 LIC. ,
above information is correct.I agree to comply with all County LICENSE NO. C./ v CLASS
ordinances and State laws regulating Heating,Ventilating and t
Air Conditioning, and hereby authorize'represen ives of this ;I SEE REVERSE FOR EXPLANATORY LANGUAGE
County to enter upon ove-mentione rope or 1
inspection purposes.
—Z
Signature of Pe i e D to .- /.