HomeMy Public PortalAbout10817 FREER ST_Mechanical__ ION
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 ther (Se/c.3800 Lab. C.) _
Policy NQ/ v Compa � 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 w=
ADDRESS
de artment. � (PRINT OR TYPE ONLY)
, � % �/��� LOCALITY---t—
Date /
Applic nt / L NO. TYPE OF APPLIANCE OR EQUIPMENT FEE C
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
CROSS 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($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU
become subject to the Workers' Compensation Laws. l ,��• �CJ LrC l e��/
i COMPRESSOR,BTU Xv--
APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers' Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. t FURNACE: FAU GRAV Y VAL ATION
LICENSED CONTRACTORS DECLARATION I FLOOR BTU /v
I hereby affirm that I am licensed under provisions of Chapter 9 HEATERSUSPENDED UNIT
:
(commencing with Section 7000) of Division 3 of the Business and WALL
Professions Code, and my license is in full force and effect.
License Number Lic.Class C-Z;?:fr
CohfiSr Date
F1Plan check fee 0
I am exempt under Sec.
B.&P.C.for this reason PERMIT ISSUING FEE$ o
Date: TOTAL FEE
LU
Signature 0-
PLAN CHECK APPLICANT (n
OWNER-BUILDER DECLARATION Z
hereby affirm that I am exempt from the Contractor's License Law NAME
for the following reason (Section 7031.5, Business and Professions m
Code): ADDRESS t•j a
❑ I, as owner of the property, or my employees with wages •�; E _ -
n[tl#
as their sole compensation, will do the work and the CITY TEL.NO.
structure is not intended or offered for sale (Section 7044, 1 J• EM`,_,
Business and Professions Code). OWNER. _
❑ I, as owner of the property, am exclusively contracting I`-ITAL-
MAIL
with licensed contractors to construct the project (Sec- ADDRESS f r•s �� __,
tion 7044, Business and Professions Code). �k_
CITY TEL.NO. t� REY(� I I e
CONSTRUCTION LENDING AGENCY a•._
I hereby affirm that there is a construction lending agency for CONTRACT ,
the performance of the work for which this permit Is issued ,
(Sec.3097,Civ.C.). ZAV4�&�,-
ADDRESS LL/I Lender's Names "` , , _ "�:-•-1 f .
q'�'�✓110 e a
CITY -/ TEL. �/� f tJ:3i t f+l s '?
Lender's Address STATE ry LIC. -
1 certify that I h ve read ap Ion and state that the above LICENSE NO 3377 CLASS
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
propert o�inspe rposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATURE OF APOF AP LI NT OR AGEN - - --- -—-DATE