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HomeMy Public PortalAbout6033 ALESSANDRO AVE_Mechanical__ ION WORKER'S have aPceSATate of consent to 76A346DPW9/89 APPLICATION FOR PERMIT LIME GREEN 76A364C I herebyaffirm that I have a`certificate of consent to self insure, or a certificate of Worker's Compensation Insurance, or a certified HEATING -VENTILATING -AIR CONDITIONING . copy thereof'(Sec.3800 Lab.C.) Policy No. Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV. O Certified copy is hereby furnished. ❑ Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN BUILDIADDRESS O 3/✓ t° �(/ V department. (PRINT OR TYPE ONLY) Date Applicant LOCALITY �P A NO. TYPE OF APPLIANCE OR EQUIPMENT FEE Cf CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST CROSS �� C COMPENSATION INSURANCE 7 ABSORPTION UNIT,BTU ASSESSOR _ (This section need not be completed if the work involved by the MAP BOOK PAGE - PARCEL permit is for one hundred,dollars($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO. PROCESSED BY I certify that in the performance of the work for which this permit is issued,. I shall not employ any person in any manner so as to I BOILER,BTU become subject to the Workers' Compensation Laws. COMPRESSOR,BTU APPROVALS DATE INSP CTOR'S SIGNATURE Date - r • Applican VENTILATION SYSTEM NOTICE TO APPLICANT: If, after making this CertoicatJ of ROUGH Exemption,you should become subject to the Workers' Compensation EVAPORATIVE COOLER provisions of the Labor Code, you must forthwith comply with such FINAL provisions or this permit shall be deemed revoked. FURNACE: FAUGRAVITY �J LICENSED CONTRACTORS DECLARATION FLOOR BTU O /d VALIDATION I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT (commencing with Section 7000) of Division 3 of the Business and WALL Professions Code,and my license is in full force and effect. License Number Lic.Class (!}ffT A d•:S T a pop. /J/� �,�/�1. .yam, �}r�j •iy'�'} 11� C•C } Contractor Date E'`IM ❑ 1 am exempt under Sec. Plan check fee i 1 1 T � V BAP.C.for this reason PERMIT ISSUING FEE$ �p°y T TAL cc 3 �° O Date: TOTAL FEE CHECK 85.75 U Signature .CHECK APPLICANT CHANGE 00 � "- a l'l7 OWNER-BUILDER DECLARATION Z I hereby affirm that I am exempt from the Contractor's License Law NAME tit for the following reason (Section 7031.5, Business and Professions ��/ 001IQ—(I0d j 3/24/93 Code): ADDRESS l F-1 1, as owner of the property, or my employees with wages 8854 1 PM12:21 as,their sole compensation, will do the work and the CITY - e� D TEL.NO. 7 97 q/ structure is not intended or offered for sale (Section 7044, Business and Professions Code). OWNER f! .r ) �rve S F-1I, as owner of the property, am exclusively contracting MAIL /v C J �l with licensed contractors to construct the project (Sec- ADDRESS 6Q 3 �j Z A✓'0 V 0 tion 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY CITY TEL.NO. •/ 1 hereby affirm that there is a construction lending agency for CONTRACTOR 0111'.the performance of the work for which this permit Is issued © /� (Sec.3097, Civ..C.). ADDRESS Lender's Name `V G CITY O TEL.NO. Lender's Address STATE {� 3 /t,77 CLASS I certify that I have read this application and state that the above LICENSE NO. .J "( information is correct. I agree to comply with all County ordinances and State laws relating to buildingJeter struction,and hereby authorize representatives of this Count upon the above-mentioned proper or inspection p seSEE REVERSE FOR EXPLANATORY LANGUAGE r� SIG A E OF APPLICANT O AGENT DATE