HomeMy Public PortalAbout10819 FREER ST_Mechanical__ 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 there f(Sec.3800 Lab. C.) ��jjyy��
Policy
` Compa `���r//O �• COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
❑ Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN BUILDING
Certified copy is filed with ta;X;R�6�
ADDRESS S�
department. (PRINT OR TYPE ONLY) r
LOCALIT;Date��_LLL ApplicaNO. TYPE OF APPLIANCE OR EQUIPMENT FEE
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($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
certify that in the performance of the work for which this permit �__
is issued, I shall not employ any person in any manner so as to BOILER,BTU �l> y
become subject to the Workers'Compensation Laws.
i
COMPRESSOR,BTU
APPROVALS DATE INSP R'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY �y
LICENSED CONTRACTORS DECLARATION FLOOR BTU p ALIDA ION
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT
—
(commencing with Section 7000) of Division 3 of the Business and HEATER: WALL
Professions Code, and my license is in full force and effect.
��
License Numb e Lia Class wi
Contractor"'AQ' �l�i��d:�_Date 0
El Plan check fee
I am exempt under Sec. O
B.&P.C.for this reason PERMIT ISSUING FEE$ 3
U
Date: TOTAL FEE `! LU
Signature PLAN CHECK APPLICANT CD
OWNER-BUILDER DECLARATION 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 F.'•..f
Eltiy_ as
I, as owner of the property, or my employees with wages
as their sole compensation, will do the work and the CITY TEL.NO. .•wi F
structure is not intended or offered for sale (Section 7044,
Business and Professions Code). OWNER I '
I, as owner of the property, am exclusively contracting MAIL TO`AL 55-0
with licensed contractors to construct the project (Sec- ADDRESS a I; — -
tion 7044, Business and Professions Code). t,;HI_':.I'; __°-r.
CITY TEL.NO.
CONSTRUCTION LENDING AGENCY CHANGE
ANGE a t Il.i
I hereby affirm that there is a construction lending agency for WADDRESS
c ,
the performance of the work for which this permit Is issued 7
(Sec. 3097,Civ.C.). f
,�j�� I;I�I`t_i—iII}iLender's Name Ld ,C/ ae NPN � - 1•//-../ ffQ TEL. •f:?31 1 Ar i•°e itLender's Addressll � '�z"� fes✓ LIC.SS
I certify that I have read this application and state at the above LICENSE NO.. 27f CLASS C'-
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 or i ct �,�' purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNA U OF APPLICANT OR AGENT DA