HomeMy Public PortalAbout10653 FAIRHALL ST_Mechanical__ VI QRKERSCOMPENSATIONDECLARATION 200046 DPW 9/89 APPLICATION FOR PERMIT LICE _ GREEN
76A364C
I hereby affirm that I have a'certificate of consent to self Insure
or a certificate of,Worker s Compensation Insurance or a certified
copy therf(Sec 3800 Lab CHEATING -VENTILATING -AIR CONDITIONING
e ) --
Policy No Company 'r��oy � L' COUNTY OF LOS ANGELES DEPT+OF PUBLIC WORKS BUILDING AND SAFETY DIV-
❑�,P � s
Certified copy Is hereby'furnished
Certified copy Is filed with the county building inspection FOR APPLICANT TO FILL IN - ADDRE SS/
department (PRINT OR TYPE ONLY) UILD
_ _O'+ + +
Date Applicant a4 7 ( �+ `~G ' NO TYPE+OF APPLIANCE OR EQUIPMENT �, FEE LOCALITY
NEAREST
ICERTIFICATE OF EXEMPTION FROM WORKERS.,. CROSS ST �v�''e / / ��5�/ 46
COMPENSATION INSURANCE ABSORPTION UNIT IBTU
(This section need not be completed if the work inv6lved by the, ASSESSOR
permit is for one hundred dollars($100)or less) k MAP BOOK PAGE PARCEL
s AIR'HANDLING UNIT CFM DISTRICT NO PROCESSED BY
I certify that In the performance of the work`for which this permit - _ `
is issued I shall not employ any person In any manner so as to _ BOILER'BTU /r
become subject to the Workers Compensation Laws - �J QP G✓_
COMPRESSOR BTU
APPROVALS DATE INSPECTOR S SIGNATURE y
Dale Applicant VENTILATION SYSTEM - 9
NOTICE TO APPLICANT' If rafter making this Certificete_of j ROUGH a + t4
Exemption you should become subject to the Workers Compensation" EVAPORATIVE COOLER
provisions of the Labor Cade you must forthwith comply with such FINAL Z
provisions or this permit shall be deemed revoked FURNACE FAU 8•-
GRAVITY _ // _ 5
LICENSED CONTRACTORS DECLARATION FLOOR BTU — �'` (p S VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER ' SUSPENDED UNIT
(commencing with Section 7000) of Division 3 of the Business and a WALL d
Professions Code and my license is In full force and'effect t T
License Number 2 45S ZZG Llc Classy (i
Contractor- `�y ��' ' Date — - ` n �D - (Ei l" 4`
r' Plan check fee _ - tG,U
I am exempt under Sec r T�I I HL „,'� a �,_6 �
B&P C`for this reason PERMIT.ISSUING FEE$ �!/� i_HE-�+ _- '
i O
Date TOTAL FEE �/G� =H�NGE �'j_' V
o ' ' W
Signature r I 1
+ ' d
OWNER BUILDER DECLARATION PLAN CHECK APPLICANT (D
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 i S
Coe) ` ADDRESS 9 n ca _
11 as owner of the property or my employees with wages
as their sole compensation will do the work and the CITY V. TEL NO
y_ structure Is not Intended or offered for sale (Section 7044
I I
Business and Professions Code) OWNER,-
I as owner of the property am exclusively contracting
with licensed contractors to construct the project,(Sec ADDRESS/70
tion 7044 Business+arid Professions Code)
CONSTRUCTION LENDING AGENCY CITY �L ^Tom/ TEL NO 7
I hereby affirm that there is a construction lending agency for CONTRACTOR t 1 G Y
the performance of the work for which this permit is Issued G
(Sec 3097,Civ C) l� ✓/�/
ADDRESS
Lender s-Name
CITY TEL NO
�Ui� C/9- 3
Lender s Address " +
STATE c LIC /y _+ r+ i ',•,•'. ~ + -, _`,
Icertrfy that I have read this application and state that the above LICENSE NO Z7, Z CLASS
Information Is correct' I agree to comply with all County ordinances
and State laws relating to budding construction,and hereby authorize '
representatives of this County to enter upon the above mentioned I n
props y for nspecUon urposes tr Y r -
SEE REVERSE FOR EXPLANATORY LANGUAGE s
SIGNATURE OF APPLICA T PENT DATE