HomeMy Public PortalAbout5702 ENCINITA AVE_Mechanical__ WdRKE
that I have
a certificate
DECLARATION 7000640 9/89 APPLICATION
FOR
PERMIT UME GREEN
]8A3a4Q Ar+o+ r'( rG �V� 1 fk,�� II'S�
I hereby affirm that I have a certificate of consent to self insure, -
or a'certlficale of Worker's Compensation Insurance, or a certified HEATING- VENTILATING -AIR CONDITIONING
copy thereof(Sec.3800 Lab.C.)_
Policy No.1`3 g t44 c/4 —Company S�y -6, COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
Certified copy is hereby furnished.
❑ Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN BUILDING
ADDRESS .94-- .
department. (PRINT OR TYPE ONLY)
Date '41 — OZ _ � Applicant &,n �Tr/�D LOCALITY �-
NO, TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
CROSSST.OR ,S 6— mA4
COMPENSATION INSURANCE �
ABSORPTION UNIT,BTU ASSESSOR
(This section need net be completed if the work involved by the MAP BOOK PAGE PARCEL '
permit is for One hundred dollars($100)or lees.) AIR HANDLING UNIT,CFM
OISPiICT NO. PROpE%EO BV
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 t0 BOILER,BTU Op J�J
become subject to the Workers'Compensation Laws. v
COMPRESSOR.BTU
- APPPOVALS GATE INSPECmR'b 51GNANPE
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
provisions of the Labor Code, you must forthwith comply with such FINAL Q—
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATION
1 hereby affirm that I em licensed under provisions of Chapter 9HEATER: SUSPENDED�UNIT_
(commencing with Section 7000) of Division 3 of the Business and a WALL
Professions Code,and my license is in full force and effect:
•Z Ste'
License Number �7'Z / Lia 8 Class �—� -
L D ACCT.: a
Contractor—Z1711 �/.I y�Ybl �[?5 Date ,3_ - 3303 U0•50 0
❑ 1 am exempt under Sec. Plan check fee 1 -ITEMS cc
B.BP.C.for this reason PERMIT ISSUING FEE $ TOTAL 80 - 50 0
F
OL
Date: TOTAL FEE d O CHECK EO.50 OL
Signature PLAN CHECK APPLICANT CHANGE - •00 Cl)
OWNER-BUILDER DECLARATION - Z
I 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 / 0000-0001 4/. 5/9b
I, as owner of the property, or my employees with wa es °Z' r GGA-fs0/-t S
❑ as their sole compensation, will do the work and the x 5727 1 AM 9�a0
p CIN TEL.NO. 4
structure is not intended or offered for sale (Section 7044.
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).
CITU TEL.NO.
CONSTRUCTION LENDING AGENCY -
hereby affirm that there is a construction lending agency for CONTRACTOR D
the performance of the work for which this permit Is issued r / /✓/J LLS %.Q/l=S
(Sec. 3097, Civ. C.). - /J c� _
ADDRESS -f !6 L aLG-14 S
Lender's Name .aC �' 2
CITY ' 16�L TEL.NO. _ j 4 I
er
Lender's Address STATE LIQ —
I certify that h ve read this app'' tion and state that the above LICENSE NO. CLASS d6—
informat'on's fact. I agr comply ith all County ordinances -
and State law relating to uil g const coon,and hereby authorize -
r'pr
esenla' s this C u to an
upon the above-mentioned
prop tion u SEE REVERSE FOR EXPLANATORY LANGUAGE
IGNATII Oi A LICANT OR AG rt GATE ,