HomeMy Public PortalAbout5224 DOREEN AVE_Mechanical__ WORKER'Shave -00 4CC COMPENSATION 4e,e9 APPLICATION FOR PERMIT
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I hereby affirm that I have a certificate of consent to self insure, 76A3
or a cer,W.ite 00NOrker'G Compensation Insurance, or a certified
copy theHEATING - VB'„NTILPTING-AIR CONDITIONING
re//�ayttt�q(Sec.3800 Lab. C.)
Policy NMUMA Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
❑ Certified copy is hereby furnished.
❑ er ifie co is filed with the count buildingInspection FOR APPLICANT TO FILL IN BUILDING
�pyrt copy y (PRINT OR TYPE ONLY) ADDRESS V
Data r. JJ—LAPPlicant _ / LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
v
CERTIFICATE OF EXEMPTION FROM WORKERS' NEARESTCROSS 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($100)or less.) AIR HANDLING UNIT,CFM MAP BOOK PAGE PARCEL
DIBIBCT No. PRocessED BY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU p
become subject to the Workers'Compensation Laws.
COMPRESSOR,BTU
APPROVALS DATE INSPECTORS GIGNANflE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, atter making this Certificate of BOUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER 52 e
provisions of the Labor Code, you must forthwith comply with such FINAL 12-�
provisions or this permit shall be deemed revoked. FURNACE: FAU_G
LICENSED CONTRACTORS DECLARATION FLOOR BTU RAVI G(' VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED—UNIT—
(commencing
USPENDED UNIT_(commencing with Section 7000) of Division 3 of the Business and HEATER: WALL
Professions Code,and my license is in full force and effect.
/Z419
Lic.Class
License Number II L
ACCT.: >
ContractorlI//��'�,.��nno/ ✓ Date ,i�,t;� div lBt9s 3303 53.900
❑ I am exempt under Sec. Plan check fee 1 ITEMS
2
BAP.C.for this reason PERMIT ISSUING FEE$ 7 U D TOTAL 53 - 90 0
Date: TOTAL FEE % CHECK, 53,90 w
SignaturePLAN CHECK APPLICANT CHANGE .00 in
OWNER-BUILDER DECLARATION Z
I hereby affirm that 1 am exempt from the Contractor's License Law NAME , f1f1
for the following reason (Section 7031.5, Business and Professions 0000-0001 3/11/96
Code): ADDRESS
❑ I, as owner of the property, or my employees with wages �� 5230 1 PM12:24
as their sole compensation, will do the work and the CITU L.NO.
structure is not intended or offered for sale (Section 7044, I _
Business and Professions Code). OWNER
❑ I, as owner of the property, am exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY TEL.NO.
1 hereby affirm that there is a construction lending agency for CONTRACTOR ,
the performance of the work for which this permit Is issued f
(Sec.3097,Civ.C.). o
ADDRESS J1 v'
Lender's Name ��
CITY TEL.NO.M
Lender's Address STATE LIC.
I 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 Slate laws relating to but construction,and hereby authorize
representatives of this County to enter upon the above-mentioned
pr5rty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
T u T DATE