HomeMy Public PortalAbout6212 BURTON AVE_Mechanical__ -
'ColAANSATION DECLARATION APPLICATION FOR PERMIT e � OL ` ��� �9
I hove a certific f nsent to self
�q a of Workers' C Tip on nce, 7 A364C /HEATING-- •VENTILATING - AIR CONDITIONING
tti"ed bOPV'nereof (Sec. 38 E-818(REV. 10/81) '
,)aIJ� Company
venif+d c y is ereby tarot COUNTY OF LOS ANGELES BUILDING AND SAFETY
xn a copy tiled wit unty Ilding in Bic FOR APPLICANT TO FILL IN BUILDING Z G
I d' art I. (PRINT OR TYPE ONLY) ADDRESS
plicant - LOCALITY ✓
11 NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
RTIFIC E OF EXkAAPTII FROM WORT RS' NEAREST
OMPENSA NSURANCE CROSS Si.
ction need not be completed if the work involved by ABSORPTION UNIT, BTU _ DISTRICT NOPROCESSED BY
nit is for one hundred dollars($100)or less.) '_
v
that in the performance of the work for which this AIR HANDLING UNIT,CFM _
s issued, I shall not employ any person in any manner BOILERBTU
become subject t0 the Workers ,Compensation Laws. / L _ — APPROVALS GATE INS TOP'S SIGN URE
COMPRESSOR, BTU �, /✓T ROUGH -
Applicant _
TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL .Z
on, you should become subject to the Workers' _ _ -
Isalion provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDA ON
mply with such provisions or this permit shall be 11
revoked. ,� FURNACE: FAU G AVITV
LICENSED CONTRACTORS DECLARATION FLOOR BTU
affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT_"
HEATER WALL
ncinq with Section 7000) of Division 3 of the Business
essions Cod a license is in full for and effect
Numb Lia Cls
te
or ate --
Im exempt under Sec. ;?9406A
Pico check fee �' i
BP.C. for this reason'
Date: PERMIT ISSUING FEE S -I # e e e s e 8
gnature TOTAL FEE l e e tL 9.7 5
Ir
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT s- � e a e 4 9.7 5
affirm that I am exempt from the Contractor's License 1
the following reason (Section 7031.5, Business and NAME G polo
8_8 8
ins Code):
as owner of the property, or my employees with ADDRESS '
ages as their sole compensation,will do the work and
e structure is not intended or offered for sole(Section CITY W.L. NO.
)44, Business and Professions Code). OWNER
as owner of the property, am exclusively contracting
ith licensed contractors to construct the project (Sec- MAIL ID
m 7044, Business and Professions Code). ADDRESS
CONSTRUCTION LENDING AGENCY CITY
affirm that there is a construction lending agency for
Durance of the work for which this permit is issued CONTRALTO
77, Civ. C.). !
ADDRES
Name
r
Address CITY TEL. N
STATE LIC.
Ihpt have read this a kation and state that the LICENSE NO. CLASS
�formalion is correct. e to comply with OP
C unty
ces and Slate laws r o in to building co tr tion,
e o e repr t es of this Cou y enter -
e abo - en r erly for ins e n rposes. SEE REVERSE FOR PLANATORV LANGUAGE
If
of Applicant r Agen ate