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Home My Public Portal About6212 AVON AVE_Mechanical__ ION DECLARAT WORKER'S I have a ce.SATate of consent to 76A346DPW9/89 APPLICATION FOR PERMIT LIME GREEN- or76A364C I hereby affirm that I have a certificate of consent to self insure, a certificate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING -.,AIR CONDITIONING copy thereof(Sec.3800 Lab. C.) �^ Policy No. �2~Company S f4 e ( Lf h © COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV. Certified copy is.hereby furnished. ' Certified copy is filed with the county building inspection FOR APPLICANT TO FILL'IN BUILDING ADDRESS 7department. (PRINT OR TYPE ONLY) P Date ! ApplicantLOCALITY NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST CROSS ST. COMPENSATION INSURANCE ABSORPTION UNIT,BTU (This section need not be completed if the work involved by the ASSESSOR MAP n / �l D/ ermit is for one hundred dollars $100 or less. MAP BOOK d !a PAG PARCEL P ( ) ) 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 BOILER,BTU become subject to the Workers'Compensation Laws. fJ COMPRESSOR,BTU 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 J provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY LICENSED CONTRACTORS DECLARATION FLOOR BTu ALID TION I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT (commencing with Section 7000) of Division 3 of the Business and HEATER: WALL � Professions Code,and my license is in full force and effect. License Number 4_0 L2 Lia Class Contractor Date 7�� 7 �K . s (� El Plan check fee ACCT_ir I am exempt under Sec. a L117 N i)n Uri O B.&P.C.for this reason PERMIT ISSUING FEE $ Q Date: TOTAL FEE Signature �• � PLAN CHECK APPLICANT C0 OWNER-BUILDER DECLARATION, �: ( I: _5te'Ltc Z I hereby affirm that I am exempt from the Contractor's License Law NAME ss- 4 for the following reason (Section 7031.5, Business and Professions ' f.`I([ji3[ fi I Code): ADDRESS ❑ 1, as owner.of the property, or my employees with wages as their sole compensation, will do the work and the CITY TEL.NO. f)E�jj — # f5; `12."s 7 structure is not intended or offered for sale Section 7044, Business and Professions Code). ( WNE � sI sl8i °= ❑ I, as owner of the property, am exclusively contracting MAIL with licensed contractors to construct the project (Sec- ADDRESS tion,7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY CI TEL.NO. I hereby affirm that there is a construction lending agency for the performance of the work for which this permit Is issued „ ,CONTRACTOR ,• ” (Sec.3097, Civ.C.). ADDRESS Lender's Name CITY ., „ 0TEL.NO. Lender's Address STATE G 1� V I'certify that I have read this application and state that the above LICENSE NO. � -!/5 Z 3 C ASS 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 property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE / � �� 7';- 7 SIGNATURE OF APPLICANT OR AGENT DATE