HomeMy Public PortalAbout9221 FLAHERTY ST_Mechanical__ WORKER'S COMPENSATION
ate of consent to 76A346DPW9/89 APPLICATIAN FOR PERMIT UME 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 hereby furnished.
❑ Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN BUILDING �j n /
department.. (PRINT OR TYPE ONLY) ADDRESS 6- I7"
LOCALITY rOr
Date Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE'
CERTIFICATE OF EXEMPTION FROM WORKERS' NEARESTCROSS ST.
COMPENSATION INSURANCE 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($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU
become subject to the Workers'Compensation Laws.
COMPRESSOR,BTU
L.. a ! /�- Applicant ✓ �! APPROVALS DATE INSPECTOR'S SIGNATURE
Date
VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificag of ROUGH
Exemption,you should become subject to the Workers' Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply,with such FINAL ��. 2
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY 13
LICENSED CONTRACTORS DECLARATION FLOOR BTU �� 3 VALIDATION
I hereby affirm that I am licensed under provisions of Chapter,9 SUSPENDED UNIT
(commencing with Section 7000) of Division 3 of the Business and HEATER:
WALL
Professions Code,and my license is in full force and effect.
License Number Jtb7 Lic.Class LI 4
Contractor `C����Date fTi '11`,4
µ `te0
❑ I am exempt under Sec. ° Plan Check fee �'--.�•:ss j, L,
e.&P.C.for this reason�rJ PERMIT ISSUING FEE$ -75- . _ J. -
_ D TOTAL FEE ```f ':;`;; W
�1,.
Signature !y�-!' t:; p;' 0
PLAN CHECK APPLICANT '-'E H.1111 "" CD
O NER-BUILDER DECLARATIO 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 - Poo.
Code): 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
tion 7044, Business and Professions Code). 1
CONSTRUCTION LENDING AGENCY CITY TEL.NO.
I hereby affirm that there is a construction lending agency for CONTRACTOR Poo.the performance of the work for which this permit Is issued
(Sec.3097, Civ. C.).
ADDRESS
Lender's Name
CITY TEL.NO.
Lender's Address 2
I certify that I have read this application and state that the above LICENSE NO. 4/ i3 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 Co y o enter u n the above-mentioned
proper y.for tion rpo eg. SEE REVERSE FOR EXPLANATORY LANGUAGE
SIG URE OF APPLICANT ORf AGEN DATE