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HomeMy Public PortalAbout4939 DOREEN AVE_Mechanical__ TION WORKER'Shave a certificate DECLARATION 76A34C 9/89 APPLICATION FOR"PERMIT: LIME-'' GREEN 0A0D 4C I hereby affirm that Ihave-a.certificate of consent to sell insure, �t or a,certificate.of Worker's Compensation Insurance, or a certified -' - HEATING•VENTILATING -AIR-CONDITIONING yll.l'I r6 (t'er 1. Seo.3800 La4. mb.. C.) . o`l�icyy N —© J Co�peny-CIiGIL/LG t: =.tT COUNTY OF LOS ANGELES' DEPT OF'PUBLIC WORKS BUILDING'AND SAFETY DIV.- CJ.: Certified copy is hereby furnished. .❑• ,Certified copy is filed with the county bull ing in p coon FOR APPLICANT TO FILL IN ADDRESS '7 '3 p� r F.*r -department." / (PRINT OR TYPE ONLY) Date �'� Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT vFEE LOCALITY �C m !, " CERTIFICATE OF EXEMPTIONWORKERS' NEAREST FROM W //j•�f�. !,� pf` COMPENSATION INSURANCE . 'CROSSABSORPTION UNIT,BTU ASSESSOR permit is for need not ed completed(SI O the work Involved by the MAPBOOK PAGE PARCEL permit is for one hundred dollars($100)or less.) ..AIR HANDLING UNIT,CFM ' - - nl$TPICTNO. PPpeE55En 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 11 F �Si do�. _ _ r_• become subject to the Workers' Compensation Laws. J //O/ COMPRESSOR,BTU J _ APPROVALS 'D TE INSPE 's SIGNATURE Date Applicant VENTILATION SYSTEM NOTICE TO-APPLICANT: It, after making this Certificate of - ROUGH Exemption,you should become subject to the Workers'Compensation EVAPORATIVE FINAL _ you must forthwith comply provisions of the Labor Cade, y p y with such provisions or this permit shall be deemed revoked. FURNACE: FAU " GRAVITY - p LICENSED CONTRACTORS.DECLARATION FLOOR BTU o ✓ _ VALIDATION ' I hereby affirm that I am licensed.under provisions of,Chapter 9SUSPENDED UNIT_ • - (commencing with Section 7000) of Division 3 of the Business and BEATER' ALL - , Processions Code,and'myyylicense is in full force:and effect. / � , License Number�y r3 Lic.Class O / - ..` 9� _ _ } y -. D o - 9 Contractor -ate - ..(� - Pam exempt under Sec. Plan check fee O BAP.C.for this reason PERMIT ISSUING FEE$ 475 (•– U Date: TOTAL FEE _ �l �?, LU Signature - - N -OWNER-BUILDER DECLARATION PLAN CHECK A/P�PLICANT " - Z '1 herebyaffirm that I am exempt from the Contractors License Law NAME �y/q •'r A E ��.�y•� �s for the following reason (Section 7031.5, Business`ano Professions a D Code)' _❑, • ADDRESS�_ I, as of the my employees with wages ✓' p .(I as their sole compensation, will do the work and the CITY S�- .t7.,�N TEL.NO. 4 L - structure is not Intended or offered for sale (Section 7044, "�•�'r��,� t7 6Fr f 1TED i' Business and Professions Code). OWNER .N/!L / (x N �� �� EJT��f'tl . .e { .0 I, as owner of the property, am exclusively contracting 6,9RIS MAIL with licensed contractors to•con struct the protect (Sec- ADDRESS 11 . tion 7044, Business and Professions Cade). CITY. _ TEL.,NO. C/-�3 � CONSTRUCTION LENDINGAGENCY ls,HAN a._ 1 hereby affirm that there is.a construction lending agency for D Rec. J e•performance of the,work for which this permit Is Issued CONTRACTOR '- • '(hS3097, Civ. C.). //�1 ,. ADDRESS Q /J 49--"e , J J .,^ � Lt I_•.I I h Lender's Name 4 CITY A)HI OA A TEL.NO� yes, /3 Lender's Address• STATE LIC- '•l+�,lam I certify that I have read this application and state that.the above LICENSE NO. `� S S�CLASS C- fel !J 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 - pr rty f rinse cti put s S. ` ' QDf� r SEE REVERSE EXPLANATORY LANGUAGE - SIGNATURE OF APPLICANT OR/AGENT •DATE -