HomeMy Public PortalAbout5328 CLOVERLY AVE_Mechanical__ ION
DECLARAT
WORKER'S I have
a certificate
of consent to 76A346DPW9/89 APPLICATION FOR PERMIT LIME GREEN.
76A364C
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
ccs,][I�VsS y thereof(Sec,.3800 Lab.C.) n /�
01 0. Ci! (/07 Company lj�J��-C�(, COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
❑ Certified,copy is hereby furnished.
Certified co is filed with the cou buildin ms coon FOR APPLICANT TO FILL IN BUILDING 'Y,�21
PY 9" P ADDRESS C� J O
department. � (PRINT OR TYPE ONLY)
Date L '(( — Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST / ✓{CROSS v Q
COMPENSATION INSURANCE L
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 -
DISTRICT NO. PROCESSED 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
become subject to the Workers'Compensation Laws. D '
COMPRESSOR,BTU
APPROVALS DATE INSPECTOR'S SIGNATURE
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
FINAL
provisions of the Labor Code, you must forthwith comply with such L
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
Professions Code,and mmyen
yyllicense
eiis in full force and effect.
License Number L[O< / Lic.Class
Contractor Date -3or�Z O
El am exempt under Seca Plan Check fel 1=
B.&P.C.for this reason PERMIT ISSUING FEE 0
Date:. TOTAL FEE �070 '00 d
-- Signature -- - - --- -— - -- --- — -- - -- - - -- :
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT Z
hereby affirm that I am exempt from the Contractor's License Law NAME ,
for the following reason (Section'7031.5, Business and Professions
Code): ADDRESS
❑ I, as owner of the property, or my employees with wages
as their sdle compensation, will do the work and the CITY TEL.NO.
structure is not intended or offered for sale (Section 7044,
Business and Professions Code). OWNER �{ Z Z� ) ' '
F-1I, as owner of the property, am exclusively contracting MAIL CC!!11 t«I` £
with licensed contractors to construct the project (Sec- ADDRESS
::: ...
tion 7044, Business and Professions Code). �/'�j /�/y� r.-EEC',;fx,
CONSTRUCTION LENDING AGENCY CITY TEL.NO.aU I ��2U /
I hereby affirm that there is a construction lending agency for , •HrlMSE
the performance of the work for which this permit 1s issued CONTRACTOR
(Sec.3097,Civ. C.). ��
ADDRESS
Lender's Name _
CITY L.NO3J3 6101 _ ..,fi1 F
Lender's Address STATE LIC. - - - -- - - -
I certify that I have read this application and state that the above LICENSE NO. (� ?77 CLASS Z U
information is correct. I'agree to comply with all County ordinances
and State laws relating to building construction,and hereby authorize
representatives of this C my to enter upon the above-mentioned
pr inspection rpos S. nn ^^�� SEE REVERSE FOR EXPLANATORY LANGUAGE
fX
SMNAIrOF APPLICANT ORAGE I NT DATE -