HomeMy Public PortalAbout5801 ENCINITA AVE_Mechanical__ ION
'WORKER'S thatIhave a certificate
of consent to 20A36,1C W 9/89 APPLICATION FOR PERMIT UAAE GREEN;
I hereby affirm that 1 have a certificate of consent to salt insure, T6A364C
or a certificate of Worker's.Compensation Insurance, or a certified HEATING -VENTILATING-AIR CONDITIONING
copy thereof(Sec. 3800 Lab. C.) -
Policy No. . Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
Certified copy is hereby furnished.
❑ Certified copy is filed with the county g inspection
buildin FOR APPLICANT TO FILL IN BUILDING r �(
department. (PRINT OR TYPE ONLY) ADDRESS aJ Os �S
Applicant LOCALITY
Dale t NT ,
0. TYPE OF APPLIANCE OR EQUIPMENT FEE / ,C•�
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREf yN�s
COMPENSATION INSURANCE CN
STROSS ST. 4
ABSORPTION UNIT,BTU ASSESSOR
(This section need not be completed if the work Involved by the MAP BOON PAGE PARCEL
permit is for one hundred dollars,(SIOO)or less.) AIR HANDLING UNIT,CFM -DISTRICT PROCESSED BY
I certify that in thnot.e ploy an of the work far which this permit - - -
is issued, I shell not employ any person imeny manner so as to BOILER,BTU / p
become subject to the Workers'Compensation Laws. 1j p ?�
COMPRESSOR,BTU 96-
_ APPROVALS DATE INSPECTOR'$61GNATURE
Data 6E io-9zIt
Ap ,oVENTILATION SYSTEM
NOTICE TO APPLICANT: If, after makingthR Certificate of ROUGH - 11,9-?q
Z
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER -
provisions of the Labor Code, you must forthwith comply with such FINAL
provisionsor this permit shall be deemed revoked. FURNACE: FAU GRAVITY
1 1. LICENSED CONTRACTORS DECLARATION FLOOR BTU S VALIDATION -
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED—UNIT—
(commencing
USPENDED UNIT_(commencing with Section 7000) of Division 3 of the Business and HEATER: ,WALL -
Professions Code, and my license is In full force and effect.
.✓/GT a 714 r
License Numbe//r��7-Lic.Class C-26
ContractoZ, 9-1a- 72-
/ 661n9T� Date 9-/o:-- 92 D ' o
❑ I am exempt under Sec. Plan Check fee - V
Q
B.&P.C.for this reason PERMIT ISSUING FEE$ - 4.0
Date: TOTAL.FEE a, _ W
Signature - d
OWNER-BUILDER DECLARATION PSN CHECK APPLICANT N'
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 .. .. ALt i .T •.
I, as owner of the property, or my employees with wages
as their sole compensation, will do the work and the CITY TEL.NO. - 3307 105.
structure is not intended or offered for sale (Section 7044, - ITEMS
'
Business and Professions Code). OWNER _ 1. 1TEI IVT -
❑ R. c ouJ
I, as owner of the property, am exclusively contracting
MAIL TOTAL 105 72
with licensed contractors to construct the project (Sec- pDDRE$$ �FieLO -
lion 7044, Business and Professions Code). �,Q CHECK. :10`.72
CONSTRUCTION LENDING AGENCY CITY n A / /O TEL.R 57 f
Lb - _ !CHANGE � '.,IfI
hereby affirm that there is a construction lending agency for CONTRACTOR �/� A./G A'G - -
Ihe performance of the work for which this permit Is issued CAIL •-' D " ' ,
(Sec. 3097,Civ.C.).
ADDRESS - i�I]i70-170019/10/92
Lender's Name - ,- _
CITY 2C /DO� TE m: 5430 .1 AM,.9,:`4
Lender's AddressTATE �+ - -
certify that I have read this application and state that the above LICENSE NO. 3J CLASS G-w�. -
information is correct. I agree to comply with all County ordinances
and State laws relating to building construction,and hereby authorize -
representativ s of this County to enter upon the above-mentioned
pro ly i nspe i n WENT
SEE REVERSE FOR EXPLANATORY LANGUAGE
9-/0SIG REOFAPPUCA ORA DATE