HomeMy Public PortalAbout4908 DOREEN AVE_Mechanical__ WORKER'S'COMPENSATION a certificate of
76A36tC 9/89 . APPLICATION FOR PERMIT UME GREEN
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I hereby affirm ihatl have a certificate of consent to self insure, �,
or a cerufftate of Worker's Compensation Insurance, or a certified "- . HEATING-VENTILATING • AIR CONDITIONING -
copy thereof(Sec.3800 Lab. C.) - -• -� `
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Policy No Company COUNTY OF LOS ANGELES --•- DEPT OF-PUBLIC WORKS BUILDING AND SAFETY DIV.
Certified copy is hereby furnished.
❑ Certifiedcopy is filed with the county building inspection ; FOR APPLICANT TO FILL IN BUILDING
department. (PRINT OR TYPE ONLY) ADDRESS �
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Date - Applicant - LOCALITY
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 ASSESSOR ,
permit is for one hundred dollars($100)or less.), AIR HANDLING UNIT,CFM_ MAP BOOK• PAGE.' - PARCEL
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I.certify that in the performance of the work for which this permit nemICT NO. PROCESSED BY
is issued, I shall not`employ any person in any manner so as to BOILER,BTU 4
become sub' cl,iIo the Workers' Compensation Laws.
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1/ T A'l k APPROVALS DATE INSPECTOR 5SGNAMAE
Date Applicant E.. I F G-L�W VENTILATION SYSTEM _
NOTICE O ADPL CANT If, after m k ng this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such _ FINAL — -
provisions or this per shall be deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOD BTU 1-e VALIDATION .
hereby,affirm that I am licensed under provisions of Chapter 9 SUSPENDED -UNIT
(commencmg with Section 7000) of Division 3 of the Business and HEATER: WALL -
- Professions Code,and my,license is in full force and effect. .
License Number rJ � v � �� Lio.Class
Contractor -rp D ' a
Pian check tee 1 ,. t�`'-s } O
❑ ,I am exempt under Se C. - - 'I I-!l yI 11-4 ® 150
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BSP.C.for this reason - PERMIT ISSUING FEE$ t'_ E{.ii lI§:i? 0
Date: - TOTAL FEE - .!:61fNt:E a! J W
Signature - PLAN CHECK APPLICANT - y
OWNER-BUILDER DECLARATION - - Z
I hereby affirm that I am exempt from the Contractor's License Law NAME _ �I.i C/ c]
for the following reason_(Section 7031.5; Business and Professions. rr�
Code): ADDRESS oc".
❑ I, as owner of ins property, or my employees with wages .
as their sole compensation; will do the'work-and the CITY ..TEL.NO.
structure is not intended or offered for sale (Section-7044, -�
r
-.•Business and Professions Code). OWNER -rlliir-"Y
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❑ I, as owner of the property, am exclusively contracting MAIL0 - _
with licensed contractors to construct the project (Sec- ADDRESSTall
tion 7044, Business and Processions Code). ��� G! ..�q`p -�
CONSTRUCTION LENDING AGENCY CITY TEL.N O
hereby affirm that there is a construction lending agency for CONTRACTOR `1 pnj
the performance of the work for which this permit is issued (�N' L'L�d i
(Sec.3097, Civ:C.). };y°.+ Iti '•jq-r,� k _
ADDRESS
Lender's Name
CITY.. ` TEL.NO(V Z -
la
Lender's Address STATE LIC.
1 certify that I have read this application and state that the above LICENSE NO" 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 "
property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE '
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