HomeMy Public PortalAbout5805 ENCINITA AVE_Mechanical__ WORKER'S COMPENSATION of consent to 20.0046 DPW 9/89 II n n E GREEN
G' n E rE- I�n
- 76A3fi4C APPLICATION FOR PER�lIIT Ir'�- I'JNO//fu1ll�7 '1�VctIJl:4�/ ISL}Iu(�II�I
I hereby a�Virm that I have's 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.
Certifiedcopy is hereby furnished.
❑ Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN ADDRESS S O
department. - (PRINT OR TYPE ONLY)
LOCALITY
Date Applicant -
N0. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCECROSS
ABSORPTION UNIT.BTU -ASSESSOR
(This section need not be completed if the work Involved by the MAP BOOK PAGE PARCEL '
permit Is for one hundred dollars(3100)or leas.) AIR HANDLING UNIT,CFM DISTRICT NO RRGtEssao ev
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
become subject t0 the Workers'Compensation Laws. - O C
' / COMPRESSOR.BTU 000 �
Dale —16 q Z Applicant VENTILATION SYSTEM APPROVALS RATE INsvecTOR's SIGNATURE
NOTICE TO APPLICANT: Ii; aft eking t4,% 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_GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU o 5_k6 VALIDATION
l hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED U
(commencing with Section NIT_
HEATER7000) of Division 3 of the Business and : WALL
Professions Code, and my license is in full force and effect. ,
our e rS n./e r 7
Y 3 SL Lie.Class �JZ U
License Number /J•f -
Contractor G'FyL G[im/Yre- Date 9-�V — V Z1 D a
Q
❑ I am exempt under Sea Plan Check fee U
&&P.C.for this reason PERMIT ISSUING FEE Q
Date: q ~
- TOTAL FEE :./o'� . , - .' - W
Signature
PLAN d
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT • q ' (n
- c 7n Z
I hereby affirm.that I am exempt from the Contractor's License Law NAME D . - CrJ�l IU•J.I
far the following reason (Section 7031.5, Business and Professions _ 1 ITEMS'
Code): ADDRESS '] _
❑ I, as owner of the property, or my employees with wages ' TOTAL 105 - 72
as their sole compensation, will do the work and the CITY TELNO. - CHECK
n �f
structure is not intended or offered for sale (Section7044, n CHECK 105.72
Business and Professions Code). OWNER /(
❑ 1, as owner of the p}operty, am exclusively contracting MAIL CHANGE - .00
with licensed contractors to construct the project (Sec- ADDRESS 2 L /GL
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY /}R.e�J/J JOO TEL. �� X10. OL;Ou-000.1 . 9/10%92
I hereby affirm that there is a construction lending agency for N - - 20 .5O
wk
the performance of the work for which this permit Is issued CONTRACTOR �A"L `G m -'G .D• 54 3 1 AMi q..,,,
(Sec. 3097, Civ. C.). -
ADDRESS 2.70 FA//C /CGL - •.` _. ..
Lender's Name //�� �.y
CITY �LAoq' j/rT /UU(TEL.fIQ'�
Lender's AddressSTA •'7 t� /�
I certify that 1 have read this application and stale that the above LICENSE NO. /•3 S� CLASS e- Z J "
information is correct. I agree to comply with all County ordinances
and State laws relating to building construction,and hereby authorize - - - '
represeg4afives OthiS County to enter upon the above-mentioned
prop for action u po SEE REVERSE FOR EXPLANATORY LANGUAGE
IiC
AE OF APPLICANT OR AGENT DATE