HomeMy Public PortalAbout9443 BROADWAY_Mechanical__ WORKER'S thatIhave a certificate of
76A34C 9/89 APPLICATION FOR PERMIT LNE GREEN
7aA364G
I hereby affirm that I have a certificate of consent 10 self insure,
or a'certificateof Worker's Compensation Insurance, or a certified HEATING - VENTILATING -AIR CONDITIONING
copy thereof(Sec.3800 Lab.C.)
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Policy o. �0� mpany ei#L 4 C91" IIV' 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
department (PRINT OR TYPE ONLY) ADDRESS �
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Data/'1—S /r KApplicant .'•r�+v LOCALITYf r-
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE -
CERTIFICATE OF EXEMPTION FROM ORKERS' - NEAREST
COMPENSATION INSURANCE CROSS
ABSORPTION UNIT,BTU ASSESSOROR
(This section need not be completed if the work involved by the -' - MAP BOOK� PAGE PARCEL '
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT CFM
wsmlcr xo. PRocEssE
I certify that in the performance of the work for which this permit B ,
is issued, I shall not employ any person in any manner so as to BOILER,BTU v
become subject to the Workers'Compensation Laws.
' COMPRESSOR,BTU
PPPfleVFLa DATE INSPELTen'S 5'GNAl11PE /ice
_Dale Applicant r VENTILATION SYSTEM _ �7
'NOTICE TO APPLICANT: If, after making this-Certificate of - ROUGH (G
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL'
provisions or this permit shall be deemed revoked. _ FURNACE: FAU A [-
LICENSED CONTRACTORS DECLARATION FLOOR BTU 51 30 VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED—UNIT—
WALL
USPENDED UNIT_ '
(commencing with GBCIIOn 7000) Of DIVISIOn 3 Of the Business and HEATER: WALL
,Professions Code.and my license is in full force antl effect.
. 4 cr.
License Number C^}b 2�L/'Y"}ic.Class L^[77 b
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Contractor �'� (,AJ Ce'WPDate ��` 3 >" V
❑ . I am exempt under Sec. Plan check fee - Q
B.&P.C.for this reason - PERMIT ISSUING FEE$ 0
Date: TOTAL FEE 20 Q - Wd
Signature
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT Z
I hereby affirm that I am exempt from the Contractor's License Law NAME D C
for the following reason (Section 7031.5. Business and Professions h-
Coe): AC.C�
ADDRESS ACCT _
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,
I iTE1 ;.
Business and Professions Code). OWNER 99-yq - s3
❑ I, as owner of the property, am exclusively contracting MAIL 11IIAL 20 A ® J 0
with licensed contractors to construct the project (Sec- ADDRESS -
tion 7044, Business and Professions Code). CHECK +�k'1• -
CITY TEL
CONSTRUCTION LENDING AGENCY .NO. - CHANGE .III-
hereby affirm that there is a construction lending agency for CONTRACTOR D
the performance of the work for which this permit Is issued
(Sec.3097,Civ.C.).
' ADDRESS _ * Ilp=1i�—il(,iili 11/ 7/94
Lender's Name - L;
CITY TEL.NO. 7JC^ 1 FI I� :.jJ .
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
rrpreaentaliv95 of this County to enter upon the above-mentioned S .
property fr speCtion rpases. SEE REVERSE FOR EXPLANATORY LANGUAGE ,
r T
SIGNATURE OF APPLI NT OR AGENT DATE