HomeMy Public PortalAbout9842 FLAHERTY ST_Mechanical__ WORKER'S COMPENSATION of consent to 76A346DPW9/89 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 hereby furnished.
❑ Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN BUILDINGTZ
department. (PRINT OR TYPE ONLY) ADDRESS S A t'LOCALITY ,1e
i
Date Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT. FEE J r c-
CERTIFICATE OF EXEMPTION FROM WORKERS'. NEAREST
COMPENSATION INSURANCE CROSS ST. O wr
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($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO, PROCESSED BY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to I BOILER,BTU /p
become subject to the Workers'Compensation Laws:
COMPRESSOR,BTU 10" C/
APPROVALS DATE INSPEC 'S SIGNATURE
Date w Applican VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after m ing IV C rtificate of ROUGH
Exemption,you should become subject to he Wor ers'Compensation EVAPORATIVE COOLER ``
provisions of the Labor Cade, you must forthwith comply with such �7 FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU D VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT
(commencing with Section 7000)of Division 3 of the Business and HEATER: WALL
Professions Code,and my license is in full force and effect.
err r OcrrArT
License Number 7 [ Y Lic.Class C2 0p_ Q '
Contractor 1'� Date
O
ElI am exe pt under Sec. Plan Check fee V
Q
B.&P.C.for this reason PERMIT ISSUING FEE$ �p. !�D O
Date: TOTAL FEE
Signature Il
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT U)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
Code):
ADDRESS
❑ 1, as owner of the property, 'or my employees with wages "?? /' 'I',
330- i1 fa Wil{a
as their sole compensation, will do the work'and the CITY TEL.NO. �
structure is not intended or offered for sale (Section 7044, 1 ITEMS t T E 'S
Business and Professions Code). OWNER r
❑ I, as owner of the property, am exclusively contracting MAIL TOTAL 2 - 00
� _ __
with licensed contractors to construct the project (Sec- ADDRESS D eir _.}#`._r¢I1i,4!I}
tion 7044, Business and Professions Code). i
'CITY TEL.NO. eG (`l Z/ iiNG , l:l
CONSTRUCTION LENDING AGENCY /7J r/ C i Zo �•f{
I hereby affirm that there is a construction lending agency for. CONTRACTOR Cfl e ,
the performance of the work for which this permit Is issued Z
(Sec. 3097, Civ. C.).
Lender's NamADDRESS r ^ pO fllri0I_lL 1 ii
/,9
CITY TEL.NO. 1913 t {it lac
0
Lender's Address STATE p �` LIC.
I certify that I have read this application and state that the above LICENSE NO. �T // 7 CLASS C 20
information is correct. I agree to comply with all County ordinances
and State laws relating to building construction,and hereby authorize
representatives of this County to enter upon the above-mentioned
property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
DAT:7
SIGN A RE OF AP AN OR AGENT DA E