HomeMy Public PortalAbout10765 FAIRVIEW AVE_Mechanical__ ION
DECLARAT
WORKER'S I have
a certificate
of consent to 76A346DPW9,69 APPLICATION FOR PERMIT LIME 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 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%bereby furnished.
Certified copyUIZIG
is filed with the county building inspection FOR APPLICANT TO FILL IN ADDRE S �
department. (PRINT OR TYPE ONLY)
LOCALITY
Date _ Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE 6-1
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
T.
COMPENSATION INSURANCE CROSS
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($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO. PRO ESSED ev
I certify that in the performancVECLARATION
ork for which t 's per t
is issued, I shall not employ ain any mann r so as to BOILER,BTU !1
become subject to the Workers' ation Laws. !/
COMPRESSOR,BTU
' APPROVALS DATE INSPECTOR'S SIGNATURE _
Date ApplicVENTILATION SYSTEM
NOTICE O APPLICANT: If, Ing this a'tifica a of ROUGH
Exemption,you should become sth Workers'Compensation
provisions of the Labor Code, yort ith comply with such EVAPORATIVE COOLER FINAL
provisions or this permit shall ber oked. FURNACE: FAU GRAVITY
LICENSED CONTRECLARATION FLOOR BTU VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT
(commencing with Section 7000)of Division 3 of the Business and HEATER: WALL
Professions Code,and my license is in full force and effect. u
Pp A
�4U`� 3c D ACCT.
Lic
License Number .Class
3303 90°45
Contractor�'rT' � Date �' 1 ITEMS 0
❑ I am exempt under Sec. _ Plan Check fee 'Ti�TAL 90 - 45 a:
B.&P.C.for this reason PERMIT ISSUING FEE$
CHECK 90.45
ate: 1p' TOTAL FEE CHANGE =U W
Signature CL
PLAN CHECK APPLICANT
OW
UILDER D/6 L RATION ! `96 Z
I hereby affirm that I m ex mpt froryS t Contractor's License Law NAME 010 � �1���� �f �f
for the following rea on ( ction 70 S, Business and Professions .� eC
Code): 7672 1 PM 4=•_t4
❑ ADDRESS
I, as owner of the property, or my employees with wages
as their sole compensation, will do the work and the CITY TEL.NO.
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 ?� l +JL1'T7�
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY �Y i TEL.NO. '1P 6`7
1 hereby affirm that there is a construction lending agency for CONTRACTOR ) 6` ,
the performance of the work for which this permit Is issued
(Sec.3097,Civ.C.).
ADDRESS
Lender's Name ? �1
CITY TEL.NO.
Lender's Address STATE LIC.
I certify that I have read this application and state that the above LICENSE NO. (O CLASS
information is correct. I a ree to comply with all County ordinances
and State laws relating t ilding construction,and hereby authorize
representatives of this o my to enter upon the above-mentioned
operty or ins on rpos SEE REVERSE FOR EXPLANATORY LANGUAGE
SI TURF OF AP NT"ENT tWTE I(q