HomeMy Public PortalAbout10109 BOGUE ST_Mechanical__ ION
WORKER'S I have
a certificate
of consehtON � 76A346DPW9/89f APPLICATION FOR PERMIT, LIME 'GREEN
76A364C
' I hereby affirm that I have a certificate of consent'td self insure, ,
or a certificate of Worker's Compensation Insurance;or a certified HEATING-VENTILATING-AIR CONDITIONING
,,copy thereof(Sec.3800 Lab.'C.)
PElolicy Rl0 Company If-1211"A OV T COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY-DIV'.
Certified copy is hereby furnished.
-1� Certified co is filed with the count bulldin inspection FOR APPLICANT TO FILL IN BUILDING'
PY Y 9 P // U-
department. (PRINT OR TYPE ONLY) ADDRESS O6 C � "
1 NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY � ✓>C
Date �-2—�Z AppApplicantOl/ Sr;�SiS 1.7on.
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
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($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO PROCESSED BY '
I certify that,in the pei}formance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU
become subject to the,Workers' Compensation Laws.
_ COMPRESSOR,BTU .3-OL B
APPROVALS DATE INSPECTOR'S SIGNATURE
Date ApplicantVENTILATION SYSTEM
NOTICE-TO'APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
.provisions of the Labor Code, you must forthwith comply with such FINAL -q/'
provisions or this permit shall be deemed revoked AC9 FAU r 1133 RAVITY 1717
LICENSED CONTRACTORS DECLARATION F BTU 610 VALIDATION
J,hereby affirm that I"am licensed under-provisions of,Chapter 9 HEATER SUSPENDED UNIT
(commencing with Section 7000) of Division 3 of the Business and WALL
Professions Code, and,my license is in full force and effect.
y (.� L kj U7-(_1E l= as
License Number 6 27
"� Lic.Class
9 a
Contractor 60 VP- SEP'S"x63 Date 7`/^�Z 0
El I am exempt under Sec. Plan check fee Q
B&P.C.for this reason PERMIT ISSUING FEE$ 0
Date: TOTAL FEE GW..
SignatureCO
OWNER-BUILDER DECLARATION PLAN'CHECK APPLICANT Z
I hereby affirm that I am exempt from the Contractor's License Law NAME ,
foi the following reason (Section 7031 5, Business and Professions
Code) ADDRESS
I, as owner of the property, or my employees with wages =it :_.i =a
as their sole compensation, will do tfie work and the CITY TEL NO '
structure is not intended,or offered for sale (Section 7044, _ y -_=r=1
,Business and Professions Code) OWNER
LL x`41 L E J.
I, as owner of the property, am exclusively contracting , MAIL h P ' r r a •
with'licensed contractors to-construct the project (Sec- ADDRESS. l % L7 G� F IY`"r;: - 4.-•,.:_ _00
OT
• tion 7044, Business and Professions Code).
CITY t-' TEL.-•NO.Cpl I{E(•.[; :,ya 1:
CONSTRUCTION LENDING AGENCY M 7 60� -• r-�f'
' .I hereby.affirm that there Is a construction lending agency for o �I
the performance of the work for which this permit is issued CONTRACTOR oule L�S7 o�S
(Sec. 3097,Civ C.). 77
ADDRESS Q 7 L/Ekr� D .
Lender's Name U [�
CITY 1^ TEL.NO. S-S / '/� ! Illt._I�II(Z ii
L )Ub,O��
Lender's Address -•.
1` _
STATE LIC. - 0 .•. - _ _ «• ;I'..t.l='�'r
r.a
I certify that I have read this application and State that the above LICENSE NO ?y 10 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 _
pr ty for ins
State,
pur es. SEE REVERSE FOR EXPLANATORY LANGUAGE
74- 91. .
SIGNAT E OFA ICA4F3R AGENT DATE - '