HomeMy Public PortalAbout5329 ZADELL AVE_HVAC_9/11/1991_ 2"0
WORKER"have COMPENSATION
certificate
of consent to 76A346DPW9/a9 APPLICATION FOR PERMIT LI E GREEN.
I'hereby affirm that I have a certificate of consent to self insure, 7sA364C
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.
Certified copy is hereby furnished.
BUILDING❑ Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN ADDR SS Cf V
department. (PRINT OR TYPE ONLY)
Date Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY
17611P* Wir
NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST.
COMPENSATION INSURANCE 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($100)or leas.) AIR HANDLING UNIT,CFM DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU
become subject to the Workers'Compensation Laws. 1
COMPRESSOR,BTU
APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL _) G �J
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY u'ALIDATION i
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9 HEATERSUSPENDED UNIT
—
(commencing(commencing with Section 7000) of Division 3 of the Business and WALL
Professions Code,and my license is in full force and effect.
License Number Lic.Class ,
Contractor Date
❑ I am exempt under Sec. Plan Check fee a
B.&P.C.for this reason PERMIT ISSUING FEE$ �� F
C
Date: TOTAL FEE Bp n
Signature U.
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT C1
1 hereby affirm that I am exempt from the Contractor's License Law NAME W VM
for the following reason (Section 7031.5, Business and Professions
Code): ADDRESS
71rY'�I I, as owner of the property, or my employees with wages
as their sole compensation, will do the work and the CITY 'r TEL.NO. �
m •-y J
Business and Professions Code). OWNER AK
❑ I, as owner of the property, am exclusively contracting MAIL I l� iL 25 _0310
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044,Business and Professions Code).
CITY TEL.NO.
CONSTRUCTION LENDING AGENCY r• r,,1 j)L.`
I hereby affirm that there is a construction lending agency for , '•YI19�3" °
the performance of the work for which this permit Is issued CONTRACTOR
(Sec.3097,Civ.C.).
ADDRESS -
Lender's Name `'C-C1 .—Q l]1 '/
CITY TEL.NO.
Lender's Address STATE LIC.
I certify that I have read this application and state that the above LICENSE NO. CLASS
Information is correct. I agree to comply with all County ordinances
d State laws relating to building construction,and hereby authorize
resentatives f this County to enter upon the above-mentioned
per for i action rposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
�- Il-q,1
P AG T DATE