HomeMy Public PortalAbout9525 BROADWAY_Mechanical__ DEC
TION I
l RKEQth COMPENSATION cafe of corse APPLICATION FOR PERMIT
reby}offirm Ihat have o certificate of consent to self
re, aLi•%ifiEate of Workers' Compensation Insurance, �bg36aC :HEATING = VENTILATING - AIR CONDITIONING
or o certified copy thPrehf (Sec. 3800,.Lob. C.)
CE'-818(REV. 10/81) - -
Policy No. Company _
Certified copy is hereby furnished. .COUNTY OF LOS ANGELES. BUILDING AND SAFETY
Certified copy is filed with the county building inspec- - - FOR APPLICANT TO FILL IN BUILDING ( '�
tion department / /AJ//A/i/', A// - - - ADDRESS
}L Pp. Co✓4�� �•a (PRINT OR.TYPE ONLY)
Date ' .A licant LOCALITY '
NO: TYPE OF APPLIANCE OR EQUIPMENT FEE.
.. CERTIFICATE OF EXEMPTION FROM WORKERS' ( � '
'COMPENSATION INSURANCE "N CROSS ST,
(This section need not be completed if the work involvad by ABSORPTION UNIT, BTU DISTRICT'NO. - ROCESSED B
the permit is for one hundred dollars ($100)or less.) ^ /,{f/(/
I certify that in the performance of the work for which this. AIR HANDLING UNIT, CFM 5l
`� V
permit is issued, Ishall not employ any person in any manner
so as to becomesubjectBOILER, BTU
to'the Workers'Compensation Laws. AvvvovnES DATE wsvE R's SIGNATURE
DateApplicant COMPRESSOR, BTLI ��� ROUGH
I '
.NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM - FINAL
Exemption; you should become subject to the Workers'
Compensation provisions of the Labor Code, you-must forth- EVAPORATIVE COOLER 6LIDAT1 N
with comply with such provisions or'this permiF'sholl be
deemed revoked. .. FURNACE: FA AVITY. - '
LICENSED CONTRACTORS DECLARATION 1 FLOOR BTU L/
. hereby affirm that I am licensed under provisions of Chapter 9 HEATERSUSPENDED UNIT_ '
:
'(commencing with Section 7000) of Division 3 of the Business WALL
and Professions Code, and my llicceennsse is in full force and effect. _ d
License Number
•--�`"r`� ' Lic Class'- - D �
Controctor&MMA/W}-l//Date O
❑ - U
1 am exempt under Sec W
-Plan check fee d
8.8P.C. for`ihis reason' sn
Date: PERMIT.ISSUING FEE $ - .a.. - Z
Signature
TOTAL FEE
- _
-OWNER-BUILDER DECLARATION • PLAN CHECK APPLICANT pG 8 03&A
I hereby affirm that I am exempt from the Contractor's License -
Law for.the follow
ing.reason (Section 7031.5, Business and NAME ay"rn�_ -)'-'f(j� - p •# a r� r..e�• 8
Professions Code): -
G yy
❑ •I, as owner of the property, or my employees with ADDRESS �.S`� - • s 3 0,5 0.
wages as their sole compensation,will do the.work and 'I c
the structure is not intended or offered for sole(Section CITY -e- TEL. NO. -
7044, Business and Professions Code): .. 's.s.e 3'05 0
❑ ,
I, as owner of the property, am exclusively contracting. OWNER � 87
With licensed contractors to construct the project (Sec- MAIL '04• 0�
tion 7044, Business and Professions Code). ' ADDRESS
CONSTRUCTION LENDING AGENCY CITY- - TEL. NO. -
I hereby affirm that there is construction lending agency for ��/
the performance of the work for which this permit Is issued CONTRACTOR' _. IY o/2) .Ari/
(Sec. 3097, Civ. C.). sir
ADDRESS �S`6- / �I� "-I�UL
Lender's Name /J
CITY 17 G?` �A'!B� .TEL O
Lender's AddressSTATEHIS
n -
I certify that I have read this application and state that the LICENSE NO. S S, CLASS
above information is correct. I agree to comply with all County '
.ordinances and State laws relating to building construction,
4nn
he by authorize representatives of this County to enter
}fieabov nmenti property for inspecypnpurposes. SEE REVERSE FOR EXPLANATORYLANGUAGE
,lf! � �'
Signature of Applicant or AgentDate