HomeMy Public PortalAbout9841 BROADWAY_Mechanical__ WORKER'Shave a certificate
DECLARATION 72�66AI14 DPW 9/09 APPLICATION FOR PERMIT LIAAE � ��
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I hereby affiim that I have a certificate of consent to self insure,
or 0:certificale of Worker's Compensation Insurance, or a certified HEATING - VENTILATING -AIR CONDITIONING
o �jeof(Sec.3800 Lab. C.)
Most I �Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
❑ Certifietl copy is hereby furnished. -." "•^
•LA \ Ce ifie copy is filed with the co t building inspectio FOR APPLICANT TO FILL IN BUILDING - . O
Z! de art nt. (PRINT OR TYPE ONLY) ADDRESS`-- YJ
Date , Applicant LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST '
COMPENSATION INSURANCE CROSS ST.
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($100)or lees.) AIR HANDLING UNIT,CFM
.
I certify That in the performance of the work for which this permit olNTRICT NoPRo Eo 9y
is issued, I shall not employ any person in any manner so as to BOILER,BTU p
become subject to the Workers'Compensation Laws.
COMPRESSOR,BTU S�
- AP N."s oaTE INSPECTORS SIGNATURE
Dale Applicant
VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption, you should'become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you most forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU 1,1 GRAVITY
LICENSED CONTRACTORS DECLARATION f FLOORBTU o VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED• UNIT_
(commericing with.Section 7000)of Division 3 of the Business and HEATER: WALL Code,'''aannddd mmyyj/lickennnss�see i�s in full force apd effect. - '
License Number_ Lia r.I.gss{�/AAVe.
AX0
Contractor D .-.. _ qCT.P Q
F-1I am exempt LIST Sec. Plan check fee - - {
p y Y 3303 1n.50¢
B.&P.C.for this reason PERMIT ISSUING FEE$ - -` - O
Date: TOTAL FEE - W
Signature 1 ITE CL
CL
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT •p
I hereby affirm that I am exempt from the Contractor's License Law NAME D •� - - TOTAL 122.50 Z
for the following reason (Section 7031.5, Business and Professions - .r, ^�Fv v7�.
Code): ADDRESS 4fIGb11 .:.
❑ I, as owner of the property, or my employees with wages :�
as their sole compensation, will do the work and the - v. - - _ '
P CITY TEL.NO. . ...
structure is not intended or offered for sale (Section 7044,
Business and Professions Code). OWNER '
❑ t, as owner of the property, am exclusively contracting 0600- 00I 8I25/95
with licensed contractors to construct the project (Sec_ AC�fq 141 IJ
DDRESS AIL - 'Z
1 AM10:41
tion 7044, Business and Professions Code),
CITY, TEL
CONSTRUCTION LENDING AGENCY
') C
I 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 1 1 •
Lender's Name IV
CITY TEL.NO�p.-
Lender's Address STATE LIG vra.� ,
I certify that I have read this application and state that the above LICENSE NO. cLAs
information is correct. I agree to comply with all County ordinances
and Oat
lacing to building construction,and hereby authorize • '
' re rf thisCounty to enter upon [he above-mentionedro purposes. 1__� SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATURE OF AP A AGENT DATE