HomeMy Public PortalAbout5502 ALESSANDRO AVE_Mechanical__ �Y7that I COMPENSATION DECLARATION 76A348 DPW 9,89 APPLICATION FOR PERMIT L' E GREEN
I he eby affirm that I have a certificate of consent to self insure, 76A364C
or a certificate of Worker's Compensation Insurance, or a certified HEATING'-VENTILATING-AIR CONDITIONING
copy thereof(Sec.3800 Lab. C.)
Policy Nc�Sf Company K 'L'!rl-
COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
Certified copy is hereby furnished. �7
Certified co Is filed with the count building BUILDING
copy y g inspection FOR APPLICANT TO FILL IN
departme9nt. y� q� (PRINT OR TYPE ONLY)
Date ' i _t ``� Applicant �NV ` �J NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
CROSS ST.
COMPENSATION INSURANCE ��ea�'DG✓f-}v(
ABSORPTION UNIT,BTU PARCEL
ASSESSOR MAPBOOK PAGE
(This section need not be completed if the work involved by the
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM DISTRICTBOO. PROCESSED ev
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 BOILER,BTU ��
become subject to the Workers'Compensation Laws.
COMPRESSOR,BTU 0c'�
APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the.Labor Code, you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR B- 59 Z, to— VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED—UNIT—
(commencing
USPENDED UNIT(commencing with Section 7000) of Division 3 of the Business and HEATER: WALL
Professions Code,and
,myy5license is in full force and effect.
License Number_ �'a Z z� Lic.Class
q/ U [-
Contractor 141/e'T� � G Date 2 Z ' L `(J , ALCTa V
EJ Plan check fee oa
I am exempt under Sec. 3303 84.70 a:
B:&P.C.for this reason PERMIT ISSUING FEE $ p 1 ITEMS U
Date: TOTAL FEE D 'TOTAL �4 . 70 uf
Signature PLAN CHECK APPLICANT H C � - 84.70 �
OWNER-BUILDER DECLARATION rCtnl,�i`'rr� n�7 Z_
I hereby affirm that I am exempt from the Contractor's License Law NAME , CHANGE .00
for the following reason (Section 7031.5, Business and Professions
Code): ADDRESS
❑ I, as owner of the property, or my employees with wages 0000 01 ���1��0
as their sole compensation, will do the work and the CITY TEL.NO. 000 0 i ht t !
structure is not intended or offered for sale (Section 7044, 852 1 AM10"-54
Business and Professions Code). OWNER '
I, as owner of the property, am exclusively contracting MAILtL
with licensed contractors to construct the project (Sec- ADDRESS 15_1jbZ Ile� rV
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY -��yf�,�. �;,� �jt.� TEL.NO�i� —7Q/
Ihereby affirm that there is a construction lending agency for CONTRACTOR �/�
the ,
performance of the work for which this permit Is issued
(Sec. 3097,Civ. C.).
ADDRESS
Lender's Name
CITY TEL.NO. -��7- ��I
Lender's Address STATE LIC.
I certify that I have read this application and state that the above LICENSE NO. � Z2-� CLASS `LO
information is correct. I agree to comply with all County ordinances
and State laws relating to building construction,and hereby authorize
representatives of this County to enter upon the above-mentioned
pro or mspe Ion purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGN URE OF APPLICANT OR AGENT DATE -