HomeMy Public PortalAbout4926ALESSANDRO AVE_Mechanical (2) ION
WORKER'S h ve a certificate
of consent to 76A346DPW9/89 APPLICATION FOR PERMIT LI E GREEN
76A364G •-
T hereby affirm 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.) 'q ,A
Policy No.06//ap Company CA 11-<Q�V�P 1 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 4 / p
department. (PRINT OR TYPE ONLY) ADDRESS ! b
Date ,3 /7 96 Applicant 6>J K!,r a NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY �� C i q 1 � o
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST `7
CROSS ST.
COMPENSATION INSURANCE ABSORPTION UNIT,BTU
(This section need not be completed if the work involved by the ASSESSOR
MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO. PROCESSED BY
1 certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU f J
become subject to the Workers'Compensation Laws.
COMPRESSOR,BTU
APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM. -
NOTICE TO APPLICANT: If, after making this Certificate of I ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATION
I hereby affirm that I am licensed under provisions of Chapter.9 SUSPENDED UNIT—
(commencing
IT,-t— / U
(commencing with Section 7000) of Division 3 of the Business and HEATER:
WALL—
Professions
ygLL Professions Code,and my license is in full force and effect. ACt``va
License Number 5 6 _)_('� Lia 3303.Class �ro ��� I 43.90
,ITEMS �
Contractor ZSA fM�S L)J(",M(J2 Date .-3 `7 �� ' TOTAL . 43- 90 p
❑ I am exempt under Sec. Plan Check fee CHECK ` 43.90
B.&P.C.for this reason PERMIT ISSUING FEE$ CHANGE ,00 0
Date: TOTAL FEE A 91) W
Signature 0000_0001 3/ 7/96 0-
�3
PLAN CHECK APPLICANT. F �f q i
OWNER-BUILDER DECLARATION C ,3 VA 5181 1 AM11a 10
I hereby affirm that I am exempt from the Contractor's License Law NAMEA
for the following reason (Section 7031.5, Business and'Professions A Me S
❑Code): ADDRESS I Soo
I, as owner of the property, or my employees with wages J o
as their sole compensation, will do the work and the CITY. 1 TEL.NO.
structure is not intended or offered for sale (Section 7044, l.. v-v✓ b -f
Business and Professions Code). OWNER i f!_
❑ 1, as owner of the property, am exclusively contracting MAIL V V
with licensed contractors to construct the project (Sec- ADDRES S PIN
tion 7044, Business and Professions Code). -
CONSTRUCTION LENDING AGENCY CITY rTE �� C I TEL.NO. / it
I hereby affirm that there is a construction lending agency for CONTRACTOR v `F ,
the performance of the work for which this permit Is issued r�� V�( I
(Sec.3097,Civ.C.).
ADDRESS - '
Lender's Name
CITY ^ ,v T �./1 L TEL.NO. f � -
Lender's Address STATE c LIC. 1
I certify that I have read this application and state that the above LICENSE NO. off- CLASS (_-DL2j
information is correct. I agree to comply with all County ordinances
and State laws relating to building construction,and hereby authorize
representativ s of this ounty to enter upon the above-mentioned
property f In ectio p oses.
SEE REVERSE FOR EXPLANATORY LANGUAGE
GNATURE OF APPLICANT OR AGENT DATE