HomeMy Public PortalAbout5803 1/2 ENCINITA AVE_Mechanical__ • t
W that I have a certiIONficate
of consent to 76AD DPW 9/89 APPLICATION FOR PERMIT L� ME GREEK.
7eA3$iC
• I hereby affirm that I have a certificate of consent to self insure. [�
or a certificate of Worker's Compensation Insurance, or a certified HEATING- VENTILATING- AIR CONDITIONING I'
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 count building inspection FOR APPLICANT TO FILL IN - BUILDING r O �?� A/C
Y 9 ADDRESS J a O 7�✓V
department. (PRINT OR TYPE ONLY)' ,
LOCALITY
Date Applicant G -
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
. NEARE
CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST. LTJ - 7-0 a,4 5
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. MAP BOOK PAGE PARCEL
P ( ) ) AIR HANDLING UNIT,CFM DISTRICT NO. PeocEsssG 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 r p
become subject to the Workers'Compensation Laws. e11 Q G
COMPRESSOR,BTU Y Eli �t9d
APPROVAIb BATE INSPECTOR SIGNATURE
Dale — Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making thi 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
provisions or this permit shall be deemed revoked. FURNACE: FAU_GRAVITV -
LICENSED CONTRACTORS DECLARATION FLOOR BTU 3 VALIDATION .,
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.
3529 LieOct r
-/e 5 eN cyT
License 5/7
Number .Class
J. p,�- V / '
D a
Contractor Date O
❑ I - - Plan check fee _ U
am exempt under Sec. r
B.aP.C.for this reason •' PERMIT ISSUING FEE $ Jr3' . . U
Date: TOTAL FEE a d
W
Signature - fL
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT ?
I hereby affirm that I am exempt from the Contractor's License Law" NAME D a
for the following reason (Section 7031.5, Business and Professions
Coe): ADDRESS
a .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. - .`;,t[1f 105.7
r+_
structure is not intended or offered for sale (Section 7044, - E
Business and Professions Code). OWNER ; + " 1. ITEMS
-
lYrR . L/v� )
❑ 1. as owner of the property, am exclusively contracting MAILl TIITRL 105 -72
Lwith licensed contractors to construct the project (Sec. ADDRESS Z Aotle G/riL - 2
tion 7044,Business and.Professions Code). 1LJ.�
CONSTRUCTION LENDING AGENCY CITY /� /DOG TEL{7V�f( () . - _ GNAhGF L•-I
I
hereby affirm that there is a construction lending agency,for CONTRACTOR GAL GL/• /fit/ e
h:,performance of the work for which this permit is issued - D -
(Sec.3097, Civ. C.). - _ w �.'F�.' • '"''•'.
ADDRESS 7-7d _qi2 2Gc�✓ ii iQf'-QI]O1 `. ?l1O/w2
Lender's Name "� - '
Cm 2C / /04,gT L _ _ - - 5451 1". AM1t),IILI
Lender's Address _
I certify that I have read this application and state that the above LOENBE NO. 7 CLASS
information is correct. I agree to comply with all County ordinances
and State laws relating to building construction,and hereby authorize -
representative of this County to enter upon the above-mentioned '
prop rty for spection pur oses. SEE REVERSE FOR EXPLANATORY LANGUAGE - " ' •� - --
q-/o -9z
IGNA URE OF APPLICANT OR AGE) DATE '