HomeMy Public PortalAbout6002 AVON AVE_Mechanical_9/9/1991_furnace ION
DECLARAT
WORKER'S I have
a certificate
of consent to 76A346DPW9,69 APPLICATION FOR PERMIT LIAAE GREEN
76A364C
I hereby affirm that I have a certificate of consent to self insure,
or a certificate of Wprker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING
copy thereof(Sec.3800 Lab.C.)
Policy No. Company. COUNTY F L ANGELES DEPT OF PUBIC W RKS BUILDING AND SAFETY DIV.
❑ Certified copy is hereby furnished.
❑ BUILDING
Certified copy is filed with the county building inspection FOR APPLICANT TO FI L I ADDRESS el 2
department. (PRINT OR TYPE ONLY)
LOCALITY �
Date Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS
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 BOILER,BTU
become subject to the Workers'Compensation Laws.
COMPRESSOR,BTU v V APPROVALS DATE INSPECTOR'S SIGNATURE
Date -/Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, aking 4&ls Certificate of ROUGH Z
Exemption,you should be ject 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 BTU / VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED-UNIT-
(commencing
USPENDED UNIT(commencing with Section 7000) of Division 3 of the Business and WALL
Professions Code,and
mylicense is in full force and effect.
License Number-ILC� Lic.Class
2
Con � �te' � O
❑ 1 am empt derS Plan Check fee U
B.&P.C.for this reason PERMIT ISSUING FEE 0
Date: TOTAL FEE U
W
Signature 11
PLAN CHECK APPLICANT CA
OWNER-BUILDER DECLARATION Z
I hereby affirm that I am exempt from the Contractor's License Law NAME ,
for the following reason (Section 7031.5, Business and Professions
Code): ADDRESS i✓ti.l;; ,g --
I, as owner of the property, or my employees with wages
as their sole compensation, will do the work and the CITY TEL.NO.
structure is not intended or offered for sale (Section 7044,
Business and Professions Code). OWNER.
❑ I, as owner of the property, am exclusively contracting MAILg-
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code). :i[I^�.•�
CITY TEL.NO.
CONSTRUCTION LENDING AGENCY
lt,L,rj-
hereby affirm that there is a construction lending agency for , 'T`�`
the performance of the work for which this permit Is issued CONTRACTO t
(Sec.3097,Civ. C.).
ADDRESS
Lender's Name LL////
CITYo TEL.,NO. ' 'i�by `7_ r i ?ilii
Lender's Address STATE LIC.
I certify that I have read this application and state that the above LICENSE NO. ,5 ?�� CLASS
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
;;er inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
URE APPLICANT OR AGENT DATE