HomeMy Public PortalAbout4937 WILLMONTE AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION 1I CEA 818 C(2-80) 1�0'>es i'"y ®II�. ®� �I�u u
I hereby affirm that I have a' certificate of consent to self
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insure, or a C,ertificatuof.Wcrk,rs'Compensation Insurance,or HEATING-VENTILATING-AIR CONDITIONING
a certified copy thereof(Sec.3800,Lab.C.)
I
Policy No. Company COUNTY OF LOS ANGELES BUILDING ARID SAFETY
Certified copy is hereby furnished.
Certified copy is filed with the county building inspection i FOR APPLICANT TO FILL IN BUILDING
department. . (Jl/
Date Applicant I (PRINT OR TYPE ONLY) ADDRESS
CERTIFICATE OF EXEMPTION FROM WORKERS' ,I
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY f �[
COMPENSATION INSURANCE NEAREST CROSS ST. 14011v a(This section need not be completed if the work involved ABSORPTION UNIT, BTuO
by the permit is for one hundred dollars ($100) or less.) DISTRICT NO. PobcESSED BY U
I'certify that in the performance' f the work for which this AIR HANDLING UNIT,CFM—' ./ •r/
• permit is issued, I shall not emp a person in any er (� 6 /j O
so as to become subject to th r) 'Comp nsatio ,I ws. BOILER, BTU H
l APPROVALS DATE INSPECTOR'S SIGNATURE W
Date . Applican i COMPRESSOR,BTUROUGH 0-
NOTICE TO APPLICANT: 1 , after making this�•ertificate of VENTILATION SYSTEM FINAL z
Exemption, you should become subject to the Workers'
Compensation.provisions of the Labor Code, you must forth- E COOLER with comply with such provisions .or EVAPORATIVC
this permit shall be - VALIDATION
deemed revoked.
LICENSED CONTRACTORS DECLARATION FURNACE: FAU GRAVITY
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 Busi- WALL
ness and Professions Code,and my license is in full force and 170effect. , ��j,,. t�
License Number Lic.Class
Contractor-` Date
I am exempt from.the licensing requirements as 1 am a
licensed architect or a registered professional engineer Plan check fee 25%of above.
acting in my professional capacity (Section 7051, Bus- r
iness and Professions Code). -PERMIT ISSUING FEE $ p
Lic.or Reg.No. ' . Date .. TOTAL FEE Q
HOME OWNER-BUILDER.DECLARATION PLAN CHECK APPLICANT
�4a
I hereby affirm that I am exempt from- the Contractor's NAME 7'�
License Law for the following reason (Section 7031.5, Busi- 4'.'a 0 o 0.8
ness and Professions Code): ADDRESS
❑ I, as owner of the property, will do the work and the ? ° °..1. I,5 O.
structure is not -intended or offered for sale (Section CITY TEL.NO.
7044,Business and Professions Code). ° ° ° 1 (a:5 O
OWNER
❑ I, as owner of the property, am exclusively contracting '' •0 3 O 5'—8 2
with licensed contractors to construct the project MAIL ^
(Section 7044,Business and Professions Code). ADDRESS
CONSTRUCTION LENDING AGENCY CITY �� TEL.NO.
I hereby affirm that there is a construction lending agency r
for the performance of the work for which this permit is CONTRACTOR
issued(Sec..3097,Civ.C.).
Lender's Name . ADDRESS
Lender's Address CITY TEL.NO.
I 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. CLASS
_CE
and tate laws regulating-Hearin , Ventilating and ;I
Air Co on and hereby a thorize esentatives of.this SEE REVERSE FOR EXPLANATORY LANGUAGE
Cou 01
n r upon th ove- ed woperty for
iI ur
S_ignat a of Permittee Date ,� y