HomeMy Public PortalAbout9535 BLACKLEY ST_Mechanical__ WORKER'S COMPENSATION a certificate
of consent to 76A346DPW9/89 APPLICATION FOR PERMIT LIME GREEN
- 76A364C
I hereby a#irm tt(at I have a certificate of consent to self insure,
qr a certificate of Worker's..Compensation Insurance, or a certified HEATING-VENTILATING -AIR CONDITIONING
copy thtireof(Sec.,3800 Lab.C.)
Policy No. Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
❑ Certified copy is hereby furnished.
❑ Certified copy is filed with the count building FOR APPLICANT TO FILL IN BUILDING
y g inspection 1l4c
department. (PRINT OR TYPE ONLY) ADDRESS
Date Applicant LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE l"
; 1
CERTIFICATE OF EXEMPTION FROM WORKERS' NEARESTCROSS ST. W v
COMPENSATION INSURANCE ABSORPTION UNIT,BTU
(This section need not be completed if the work involved by the ASSESSOR
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permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
_ DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to I BOILER,BTU
become subject to the Workers'Compensation Laws. G'
COMPRESSOR,BTU
APPROVALSDATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU G AVITY 1
LICENSED CONTRACTORS DECLARATION FLOOR BTU /r &-0 VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT
(commencing with Section 7000) of Division.3 of the Business and HEATER: WALL
Professions Code, and my license is in full force and effect.
License Number Lic.Class
Contractor DateM^ O
El • I am exempt under Sec. Platt Check fee w V
B.&P.C.for this reason.
PERMIT ISSUING FEE'$ O
Date: TOTAL FEE d UJ
d
Signature PLAN CHECK APPLICANT CD
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
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?) ADDRESS '?F.:'4.• s 7 _{
I, as owner of the property; or my employees with wages 1 it i
as their sole compensation, will do the work and the CITY TEL.NO.
structure is not intended or offered for sale (Section 7044, I '.Y C C
Business and Professions Code). OWNER _
F-1
I, as owner of the property, am exclusively contracting MAIL = 0
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with licensed contractors.to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CISY / TEL.NO..J C s« r€ t�
I hereby affirm that there is a construction lending agency for CONTRACTOR
I performance of the work,for which this permit Is issued
(Sec. 3097, Civ. C.). .
ADDRESS fel"tt'Fj j
Lender's Name —r;-- Art
CITY TEL.TEL.NO. • its IJ, y
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
and State laws relating to building construction,and hereby authorize
representatives of this County to enter upon the above-mentioned
P P ty for inspection purposes. 9 SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNA-rUA1E OF APPLICANT OR AGENT ATE