HomeMy Public PortalAbout4941 DOREEN AVE_Mechanical__ -WORKER'S
have a CNSATION DECLARATION 76A3" DPW 9/89 - APPLICATION FOR PERMIT LIME GREEN,
I heregy affirm that I have a certificate ofconsent to self insure, ]6A364C
ore Certificate oh worker's Compensation Insurance, or a certified HEATING •VENTILATING•AIR CONDITIONING
copy thereof(Sec.3800 Lab.C.) CC
Policy No. CompanAW&E ' FVA'D COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV. _
P - Certified copy is hereby furnished. .
❑ copy y building action FOR APPLICANT TO FILL IN BUILDING y�y. l2/1
Certified co Is filed with the count buildin ADDRESS
-depa Cnt. (PRINT OR TYPE ONLY)
Date 92APPIicante fsll' � LOCALITY T67-
NO. TYPE OF APPLIANCE OR.EQUIPMENT FEE r r
NEAREST r -
CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST. r
COMPENSATION INSURANCE '
.ABSORPTION UNIT,BTU Fe
ASSESSOR
.(This section need not be completed if the work involved by the
MAP BOOK. PAGE PARCEL
permit that i onehundred
performance
anceI f the or for AIR HANDLING UNIT,CFM GISTRICT NO. PROCESSED By -
I certify that in the performance of the work for which this,permit
is issued, I shell not employ any person in any manner 50 as to BOILER,BTU �Dl .�
become subject to the Workers'Compensation Laws. ' � L�
COMPRESSOR,BTU �B
/
. Date Applicant APPROVALS PATE INSPECTOR'$SIGNATURE
VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this ROUGH
Certificate of _
Exemption,you should became subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Codti you must forthwith comply.with such FINAL 2J w7 y'
provisions orthis permit shall be deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU O 1190d7 J S VA IDATION ,
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 my license is in full force and effect.
v
Go �GL4.Ge J i
License Number 79�3�5' Lia Class e—aD Hh.L. IT
.. D AQ y`r Q p �L D iil 1 9 }
Contractorll YJ/Ar/ //YC=*///opera r -9 1 1 ' �-�0 ' CLCL
❑
Plan check fee - "1 - -a -T U lam exempt under Sec, I U I A_ y_-i P.-!:I Ir
• B.&P.C..for this reason PERMIT ISSUING FEE !F1 Z5__
Date: TOTAL FEE 3 CCA*!(& � ,r(r( w
Signature d
PLAN CHECK APPLICANT/,, (n
OWNER-BUILDER DECLARATION _ Z
I hereby affirm that I am exempt from the Contractor's License Law - NAME D /= D IjI�V_j I (II�{_'y t_,/ 1. 2
for the following.reason (Section 7031.5, Business and Professions Vol•, „ •— �� T��' -
J /� 1�%r( - All ll.-il
�e' ADDRESS v A'GE r E I/T . _ Ir
I, as owner of the property, or my,employees withwages
as their sole compensation, will do the work and the CITY - ('f A ���.�1 TEL.NO.
structure is not intended or offered for sale (Section 7044. .5 A tq _
Business and Professions Code). OWNER R S 0 ti �%R v�[ n/✓ - '
❑ I, as owner of the property, am exclusively contracting MAIL 7-/- 7-
with licensed contractors to.Construct the project (Sec. ADDRESS `, .�, tP�R TF_; S
-tion 7044, Business and Professions Code). - -
CONSTRUCTION LENDING AGENCY CITY 49n e d 0TEL.NO. 1--7 '/n 3 Gi
hereby affirm that there is a.conslruction lending agency for CONTRACTOR O /_ /�A 'i�/� - D
the performance of the work for which this permit Is issued .J !� G'
(Sec..3097,Civ.C.). - n
ADDRESS 0 /, 3 O rS
Lender's Name j/� '
CfTY % !'^ R/- TEL NO.7 5� n 7-Q _
Lender's Address ATEP _
I certify that I have read this application and state that the above L CENSE NO. ' CLASS' Q
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 t nspectio ur s. SEE REVERSE FOR EXPLANATORY LANGUAGE.
SIGNATURE OF APPLICANT OR AGENT .DATE