HomeMy Public PortalAbout9423 BROADWAY_Mechanical__ WORKER'S thatIhave a certificate of
'BA3154C W9/89 APPLICATION FOR PERMIT UME GREEN
8A364C
I 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.) Jn r •• - .
Policy N.S_15l�C.mpany�DG.Ly �'(•L.
"COUNTY OF LOS ANGELES. .DEPT OF PUBLIC WORKS - BUILDING AND SAFETY DIV.
Certified copy is hereby furnished.
Certified copy is fled with the county building inspection ' FOR APPLICANT TO FILL IN ADDRESS `I 23 e Nl I
`1 department. /ny.� r (PRINT OR TYPE ONLY) `
Date r ', Applicant d r ✓�— •'�� ��C/ NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
LOCALITY iJyJ�'[�
CERTIFICATE OF EXEMPTION FROM WORKERS' - C OSS STNEAREST: f}LE�Ss}.�i,p
ABSORPTION UNIT,BTU �O
COMPENSATION INSURANCE - S
ASSESSOR
(This section need not be completed it the work InvolVad by the - MAP BOOK .PAGE PARCEL
permit is for one hundred dollars(5100)or less.) AIR HANDLING UNIT,CFM
LYSTFICi NO. FnnCESSEe 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 •
-Dale -Applicant VENTILATION SYSTEM APPRovALs DATE rNSPECTORS SIGNATURE .
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 T GRAVITY r
LICENSED CONTRACTORS DECLARATION FLOOR BTU to GO VALIDATION
1 hereby affirm that ) em licensed under provisions of Chapter 9 ENDED UNIT_
(commencing with Section 7000) of Division 3 of the Business and HEATER: SSUSPUSS
Professions Code,and my license is in full force and effect.
ALL
License Number 7� 22A Lia Class`^ ^�^�' 412-0
V
tc D ACCT.r y
Contractor /-}i7� —Tgo /w" Data ► 2, 3! -q� - - - - _ 3303 _ 109.90 p
❑ I am exempt under,Sec. PIBD check fee - - 1. ITEMS cccc
B.BP.C.for this reason - PERMIT ISSUING FEE v TOTAL 109 O
Date: TOTAL FEE CHECK 109.90 w
Signature PAN CHECK APPLICANT :CHANGE •00 o-
OWNER-BUILDER DECLARATION Z
I hereby affirm that I am exempt from the Contractor's License Law NAME Dt
for the following reason (Section 7031.5, Business and Professions 0000-0001 4/25/96
Code): ADDRESS -
❑ I, as owner of the property, of my employees with wages6070 1 PM 4:59.
as their sole compensation, will do the work and the CRY .TEL_NO.
structure is not intended or offered for sale (Section 7044,
Business and Professions Code). OWNER �J�(� 7 �• D . � �
❑ I, as owner of the property, am exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRESS � �Q H'�Al•l.x'q" , .
rofessions Code).
tion 7044,CONSTRUCTION PLENDING AGENCY - CITY �m� �.lTw TEL.NO.z�6_ Gi
I hereby affirm that there is a construction lending agency for CONTRACTOR , _1 /
the performance of the work for which this permit Is issued
(Sec.3097, Civ.C.). NNO._J
ADDRESSD _ ^f+•;n
Lender's Name
CITY p� /�3(D AAS• ,/1 TEL
�/�•[j / - _ _..
BION' L. �j�5_?_5 5
Lender's Address
I certify that I have read this application and state that the above LICENSE NO.STATE L��Z,Z� C ASS C^ 2—�
information is correct. I agree to comply with all County ordinances
and State laws relating to building construction,and hereby authorize
repress 'ves of this County to enter upon the above-mentioned
prop ty f inspectiorlpurposes. - SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATURE OF APPLICANT OR ADEM DATE -