HomeMy Public PortalAbout5708 OAK AVE_HVAC_8/24/1994_WOVKER'S COMPENSATION DECLARATION 200046 DPW 9/89
I hereky affirm ih,l I have a certificate of consent to self 'sure, 6A364C
or a cehi!icate of Worker's Compensation Insuranc a certified
copy thereof (Sec. 3800 Lab. C.)
Policy No. Com
❑ Cenifietl coDY is h y furnished.
❑ Certified y Is filed with the county building inspection
Date Applicant
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the work Involved by the
permit is for one hundred dollars ($700) or leas.)
I certify that In the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to
become sublect to the Workers' Compensation Laws.
r
Date Applicant
NOTICE TO APPLICANT: If, atte making this Certificate of
Exemption, you should become subject to the Workers' Compensation
provisions of the Labor Code, you must forthwith comply with such
provisions or this permit shall be deemed revoked.
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapt
(commencing with Section 7000) of Division 3 of the Bus' s and
Professions Code, and my license is in full force and,0066—t.
License NumberI fc. Class
Contractor / net.
❑ I am exempnder Sec.
B.BP. for this reason
nate:
G
Signature
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law
t
he f lowing reason (Section 7031.5, Business and Professions
e):
I, as owner of the property, or my employees with wages
as their sole compensation, will do the work and the
structure is not intended or offered for sale (Section 7044,
Business and Professions Code).
❑ I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec-
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending a e or
the performance of the work for which this per Issued
(Sec. 3097, Civ. C.).
Lender's Name
Lender's Address /
I certify that I have realifthis application and state that the above
information is torr I agree to comply with all County ordinances
and State law lating to building construction, and hereby authorize
represent es of this County to enter upon the above-mentioned
kgrape f/��( Inspection purposes. e
'IONAILREOFAPPLICANT ORAOENT GATE
APPLICATION FOR PERMIT `IME GREEN
HEATING - VENTILATING - AIR CONDITIONING
COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS
BUILDING AND SAFETY DIV.
C
FOR APPLICANT TO FILL IN BUILDING (ADDRESSQom
,
(PRINT TYPE ONLY) /
' LOCALITY
IIVY'� �'U��"!!
NO. TYPE OF APPLIANCE OR. EQUIPMENT _ r. FEE
NEAREST 1
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INC)INC)c� n
n
ABSORPDN urvu, m ASSESSOR
I ' MAP BOOK
PAGE PARCEL
AIR HANDLING UNIT. CFM GSRlRICT No.
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BOILER, ST -I
COMPRESSOR. BTO �Da � /{,) 7Jl
APf Pii., SDATE
INSPECTORS SIGNATURE
VENTILATION SYSTEM
-` (ROUGH
I EVAPORATIVE COOLER FINAL
EZ % k
Y —1
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FURNACE: FAU —BTU G/ vUVUU VALIDATION
I FLOOR/ IJVUNIT_
USPENDED
HEATER: SUSPENDED—UNIT-
_ WAV
-
3303 li. is
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N EMS
O
Plan check fee�� 9,6
TO i AL 12.2 o 225
m
PERMIT ISSUING FEE $
CHEI.X%,
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TOTAL FEE ��i�-. o'�. ..
CHANGE� .Gift
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PLAN CHECK APPLICANT
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NAME
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ADDRESS
CITY TEL. NO.
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CITY TEL. NO.
STATE LIC.
LICENSE NO. CLASS
SEE REVERSE FOR EXPLANATORY LANGUAGE
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