HomeMy Public PortalAbout9720 BROADWAY_Mechanical__ WORKER'Shave &004COMPENSATION 76A346 DPW 9189 APPLICATION FOR, PERMIT DACE GREEN
' 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.)
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Policy No.I�I O_C I Company ST&7-e �'u3 COUNTY OF LOS ANGELES ' - DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
❑ Certified copy is hereby furnished. 7 ,/-'75
ECertified co Is filed with the'count building inspection FOR APPLICANT TO FILL IN - BUILDING ['�����R
it /nmentPy y 9 p-- (PRINT OR TYPE ONLY) ADDRESS GJ -
Dale r/ ) 771 - Applicant v �VI/ NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY �. C'r
CERTIFICATE OF EXEMPTION FROM WORKERS' NEARECROSS ST
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. . - COMPENSATION'.INSURANCE - ���/� � /
ABSORPTION',UNIT,BTU - ASSESSOR - '
(This section need not be completed if the work Involved by the MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
olsmicr Ro. PRacssssD BY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU 49O!
become subject to the Workers' Compensation Laws. -
COMPRESSOR,BTU �
Dale Applicant VENTILATION SYSTEM APPROVALS ogre INSPECTORS SIGNATURE
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption, you should became subject to the Workers'Compensation EVAPORATIVE COOLER
,provisions of the Labor Code,
.you must forthwith comply with such FINAL '
provisions or this permit shall be deemed revoked. .FURNACE: FAUAVITY i
LICENSED CONTRACTORS DECLARATION FLOOR - BTU _ ALI ATION
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED - UNIT_ -
(commencing with Section 7000) of Division 3 of the Business anE WALL
Professions Code,and my license emirs in full force and effect.
License Number -� y C/ Lia ;7-Class `- C)l - Y
Conlraclor�/Vf-'�'T"'n'-y�`� Date
❑ I - Plan check fee - V
am exempt under Sec. _ cc
B.&P.C.for this reason - PERMIT ISSUING FEE$ !� 5 o O
Date: TOTAL FEE - .zZ� ACCIT.i _ a
-
Signature r-Clc«..r,.
OWNE UILDEfl CLARATION PLAN CHECK APPLICANT 3307 71.25 N
I hereby affirm that I am exempt from the Contractor's License Law NAME D - 1 ITEMS
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for the following reason (Section 7031.5, Business and Professions . 71. 25
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Cade): ADDRESS TOTAL ! 1. ?S
❑ I, as owner of the property, or my employees with wages. CHECK 71.2`
as their sole compensation, will do the work and the 1 `r
p CITY TEL.NO. ,
structure is not intendedor offered for sale (Section 7044, CHANGE - .O(I
Business and Professions Code). OWNER
❑ 1, as owner,of the property, am exclusively contracting - ^ .. _
MAIL
with licensed contractors to construct the project (Sec- ADDRESS /tog, /yto-fb Y L-/3-CA. 1 . 0000-0001 S/14 92
- tion 7044, Business and Professions Code). - _ --
CONSTRUCTION LENDING AGENCY
OITY -CAVI rVry - TELNO. p�- ('G�� .5029 1AM10:4,5
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.). -Y -
ADDRESS I Z—
Lender's Name //� q
CRY A-2 V I!1 L- , 17Gz. TEL.NO. C G-7a 2 -
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Lender's Address - STATE ` 6 _ LIC. - -- _
I certify that I have read this application and state that the above LICENSE NO. , 0 D �a. CLASS
information is correct. I agree to comply with all County ordinances
and State laws relating to building construction,and hereby authorize -- - -
representatives of,this County to enter upon the above-mentioned '
prop y fq_r inspec' purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE''
SI NATURFr, FAPPLICAI AGENT DATE -