HomeMy Public PortalAbout5217 WILLMONTE AVE_Mechanical__ 76A364'C � -
Ii�S COMPENSATION DECLARATION APPLICATION
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~�QQI�� •: ,CE-818(2.80) Epi ����'®tl�1 ��Ifs I�G I �..��_.
•I}ie ebly rfirnT,that I fisve a- certificate of consent to self
''^irrsare�r a ceri9ficate of Workers'Compensation Insurance,or I-EATIRIG-VENTILATING-J lUR CONDITIONING
av ertified copyl'thereof(Sec.3800,'Lab.C.) '
Policy Ng„ Company.
❑ Certified copy is.hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
❑ Certified copy is filed'with the county building inspection BUILDING ) �,(
department. FOR APPLICANT TO FILL IN ADDRESSl.��f � 14// /�/ 0AJ/
Date Applicant (PRINT OR TYPE ONLY)
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY
dr
COMPENSATION INSURANCE' NEAREST }
(This section need not be completed if the work involved ABSORPTION UNIT,BTU CROSS ST. a0
by the permit is for one hundred dollars ($100) or less) 1. DISTRICT NO.I• P C ED 9Y V
I certify.that in the performance of the.work for which this I, AIR HANDLING UNIT,CFM W
permit is issued, I shall not employ any,p.erson in any manner �O
;Ps to become subject to the Worker 'Compensation Laws. I :' BOILER,BTUQ� APPROVALS' TE INSPECTOR'S SIGN REWe •� y Applicant.`��� i /�+ �. _ IL
rt .COMPRESSOR,BTU' ROUGH :
NOTICE TO APPLICANT: If, after making this Certificate of
VENTILATION SYSTEM
Exemption, you should become,'spbject•.to the Workers' FINAL
Compensation provisions of the Labor Code;you must forth- ; EVAPORATIVE COOLER VALIDATION
with comply with such.-provisions or this permit shall be ` •
deemed revoked. r
LICENSED CONTRACTORS DECLARATION ! FURNACE: FAU
FLOOR: BTU
I hereby affirm that I am licensed under provisions of Chapter : HEATER: SUSPENDED UNIT
9 (commencing with Section 7000)o.f Division.3 of the Busi-.. �. WALL ,
ness and Professions Code.,and my licens..e is in_full force and. 54
effect. l .
License Nu /4c.. ssL
Cont
❑ I am. exempt from the licensing requirements as 'I am 'a
licensed architect or. a registered .professional engineer Plan check.fee 25%of above.
acting in my. professional capacity (Section 7051, Bus-
iness and Professions Code).' PERMIT ISSUING FEE$
,Lic.or Reg.No. Date ` TOTAL FEE
HOME OWNER-BUILDER DECLARATION PLAN,CHECK APPLICANT
I hereby affim that I am" exempt from'.the .Contractor's,. NAM..EI
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Coda): ADDRESS
❑ I, as owner of the'property, will do the work and the
structure is. not intended or offered' for sale (Section CITY ' TEL.NO. I `t:- J.1.Ni
7044, Business and Professions Code).
❑ OWNER f,� / C - :.C,'I-,
I, as owner of the property, '4
am exclusively contracting ✓•• v 6
with licensed' contractors to-construct the projectADDRESS
AIL t. 30,;5JD
(Section 7044,'Business and Professions Code). i ADDRESS
}:E. fr
5.2
G
CITY�` TEL.NO. _0_'5=
CONSTRUCTION LENDINAGENCY I
I hereby affirm that there is a construction lending agency• It:
for the performance-of the work for which this permit is CONTRACTOR
issuedSSec.3097,Civ.C.):
Lender s Name ADD14ESS -F %87
Lender's Address CITY'.. TEL.N %.!: �b
I certify that I have read this application and state that the STATE / LIC. At 7'v41
above information is correct.I agree to comply with all County LICENSE NO. CLASS G Za
ordinances and State laws'regulating Heating, Ventilating and
Air Conditioning,and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
County to enter upon the above-mentioned •p2pety for , '
�inspecu�pur, sea._ mittee Date
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