HomeMy Public PortalAbout9661 BROADWAY_Mechanical__ r •
WORKER'S
haveCOMPENSATION DECLARATION 7BA364 DPW 9/89 APPLICATION FOR PERMIT. UME ,: REEK
tHH:04 C
ilercby'�irm that I have a certificate of consent to self insure,
-ora certificate of Worker's'Compensation Insurance, or a certified HEATING.VENTILATING - AIR CONDITIONING
copy that of Sec.38 C.)
i
• P❑alicy N company COUNTY OF LOS ANGELES DEPtf OF PUBLIC WORKS BUILDING AND SAFETY DIV.-
. Certified copy is hereby furnished.
❑ C died.ca �s filed with the count buildingins tip FOR APPLICANT TO FILL IN BUILDING
d an py y (PRINT OR TYPE ONLY) ADDRESS
1�'/�Iyf� LOCALITY
Date I Applican ` ' � NO. TYPE OF APPLIANCE OR EQUIPMENT FEE '
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
CROSS ST.
COMPENSATION INSURANCE ABSORPTION UNIT.BTU -
(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
GISIRICT NO. PPOCE$$E09Y
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 -
APPROVALS DATE INSPECT OR5 UGNATIRE'
Date Applicant VENTILATION 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
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY -
LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATION
I hereby..affirm that I am licensed under provisions of Chapter 9 SUSPENDED - UNIT_
(commencing with Section 7000) of Division 3 of the Business and HEATER: WALL '/tM/cfl-'C � �T•
Professions Code,and my license is in full force and effect.�• •vP/Wy�atT�
License Number D l/�5 Lic.Class
Contract Date - D O
❑ I am exempt under Sac. Plan check fee - - Q
cc
BAP.Cf for this reason PERMIT ISSUING FEE ' O
Date: TOTAL FEE O L)
W
Signature - - d
OWNER-BUILDER DECLARATION "' PLAN CHECK APPLICANT 8 Z
I hereby affirm that I am exempt from the Conlractoi s License Law NAME -
for the following reason (Section 7031:5, Business and Professions' D ACCT.:
Cade): ADDRESS 3303 80.50
❑ 1, as owner of the property, or my employees with wages as their sole compensation, will do the work and the CITY TEL.NO. - 1 ITEMS
structure is not intended or offered for sale (Section 7044, M1 cp3f'f 'Q
Business and Professions Code). . OWNER - TOTAL 80 -5
❑ I, as owner of the property, am exclusively contracting MAIL CHECK 80.50
- with licensed contractors to construct the project (Sec- ADDRESS
lion 7044, Business and Professions Code). CI TEL.NO. CHANGE .00
CONSTRUCTION LENDING AGENCY '
hereby affirm that there is a construction lending.agency for 'CONTRACTOR / 7 -
tha performance of the work for which this permit Is issued -
(Sec.3097,Civ.C.). I 0000-0001 J 1/9b t
ADDRESS aV 4682 1 PM 6:10
Lender's Name
CITY TEL.NO,
Lender's'Address STATE LIC. -- -
I certify that I havereadthis application and state.that the above .LICENSE NO CLASS
information is correct.-I agree to comply with all County ordinances
and Stat laws relating to building construction,and hereby aut rize
repres tatives of this County to enter upon the abov -ment neq -
'pr�PAPe
for inspection ur cies
/ SEE REVERSE FOR EXPLANATORY LANGUAGE ..
aIGOF APPLIC ORA T G ATE