HomeMy Public PortalAbout9556 BROADWAY_Mechanical__ WORKER'S
thatIh veace'SATIONDECLARATION 2aG04sDPW 9/89 - APPLICATION FOR PERMIT �� .�. ��,���{+-
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I hereby affirm that I have a ceY,ilicate of consent toself insure
or a certificate of Workers Compensation Insurance or a.yenified �' HEATING- VENTILATING- AIR CONDITIONING
copy theleoir•Sec:6800 Lab. C.) t - , - -
Policy No. Company COUNTY,OF LOS.ANGELES.. -. - DEPT OF PUBLIC WORKS` BUILDING AND SAFETY DIV.
❑ •' Certified copy is hereby furnished 0 - -
❑ Certified copy,is filed with the county'building inspection -FOR APPLICANT TO'FILL IN - BDDDUlL WG
department. • (PRINT OR TYPE ONLY) ADDRESS
Date uO Applicant NO. Iry
TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY
CERTIFICATE,OF EXEMPTION FROM WORKERS' NEAREST -
COM PENSATIONINSURANCE " CROSS ST. _
ABSORPTION UNIT,BTU Tif
(This section need not be completed if the work,involved by the - ASSESSOR ���MAP BOOK PAGEy'
' Ci PARCEL
permit.that-in
for i onenthe ntlretl dollars f the or less wh AIR HANDLING UNIT,CFM_ DISTRICT No. PROCC..ED ev
' I certify�,haD in the performance of the work forwftich this permit 1 ,
is issued; I shallnot employ any person in any manner so as to BOILER,BTU -
become subject to the Workers'Compensation Laws.
- COMPRESSOR,BTU
Date ^ Applicant • » APPROVALS DATE INSPE.1;As SIGNATURE
VENTILATION SYSTEM_ P.
NOTICE TO APPLICANT: If, after making-this'-Certificate of _ ROUGH '
Exemption,you.shouid become subject to the Workers'Compensation
EVAPORATIVE COOLER -
provisions of the Labor Code, you timed revoked.th comply with such - FINAL ^ZL
provisions or this permit shall be deemed reyoketl. FURNACE: FAU_GRAVITY- .
LICENSED CONTRACTORS DECLARATION / FLOOR BTU Lo 42i2D 60 VALIDATION
I hereby affirm that I am licensed.under provisions of Chapter 9 SUSPENDED UNIT_ -
(commencing with Section ]000) of Division 3 oHEATER:
f the Business and WALL . �-
Professions Code;and my license is in full force and effect: - - -
6`a ACnC;Tf.s C
License Number Lip.Class - a-V - 3,�t0,V 135.10
D 1-ITEMS o
Contractor Data i c
❑ I am exempt under.Sec. Plan Check-.fee - - - TOTAL 135 yaJ. O
BAP.C.for this reason PERMIT ISSUING FEE$ CHECK 135 lI) O
Date:
T CHANGE .00 v
TOTAL FEE /O - W
Signature - OL
+ OWNER.BUILDER_DECLARATION PLAN CHECK APPLICANT _ 0000-0001. .2j 1/96-.,Z
I hereby affirm that I am exempt from the Contractor's License Law NAME �I•, D 4667 1 PM12:10
for the.following reason (Section 7031.5, Business anal Professions •. •
Code): ` ADDRESS
Q. -
' . f ;
I', as owner of the.property, or my employees
as their sole compensation, will do the walk and the CITY _ TEL.NO. '
structure is not intended or offered for sale(Section 7044,
Business.and Professions Code). WNER .
❑ - I, as owner of the property, am exclusively contracting MAIL,with licensed contractors to construct the project (Sec- ADDRESS -
tion 7044. Business and Professions Code).
/�/qn•�� 1 .
CONSTRUCTION LENDING AGENCY-� '- CITY•T /�- - u�C= N _i < - _ . . - •� - . ti _-
.-
Ihereby affirm that there is a construction whictis perm agency for CONTRACTOR
the performance of the work for which this permit Is issued "
(Sec.3097, Civ.C.).
F S"
' ADDRESS ... - _ . . ..
Lender's Name '
CITY - TEL NO. -Lender's Address _.
TE
certify'that I have read this application and-state that the above - LICENSE NO. C ASS -
ormation is correct. I agree to comply with all County ordinances
State laws relating to building construction,and hereby authorize
esentatives of this County to enter upon the above-mentioned
ty for inspection purposes. SEE REVERSE FOR.EXPLANATORY LANGUAGE • Y
1/1 Af
URE OF AP LICANTO AGENT, �.I DATE - .^ ,