HomeMy Public PortalAbout9006 GARIBALDI AVE_Mechanical__ COMPENSATION of consent to MDWef� APPLICATION FOR PERMIT LIME GREEN
I tieretiy affirm that I have a certificate o} consent to self Insure,
.-br a oertifloate of Worker's Compenaatlon Insurance, or a certlfled HEATING-VENTILATING-AIR CONDITIONING
oopy thereof(Hao.3800 Lab. C.)
Polloy No. CorrprTf' COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
Certified copy Is hereby furnWvx.
❑ Centred Dopy b sled with the county bulking InepFOR APPLICANT TO FILL INeotbn BURXqNG
dap-M-1. RI
(PRINT OR TYPE ONLY) ADDRESS
P
LOCALITY
Pate APdIcartt NO. TYPE OF APNIANCE OR EQUIPMENT FEE
N>J4REBT
CEFMFICATE OF E)CEMPTION FROM WORKER it8' CROSS 8T.
COMPENSATION INSURANCE AB ypN UNrT BTU
(This seatlon need not be completed H the cork tnvotved by the MAP BOOK PAGE el PARCL�f
permit Is for one hundred dollars($100)or Nee..) AIR SUNG UN-M CFII
ornrw-r No. Prooaeam IN
I certify that In the performance of the work for which this permit
Is Issued, I shall not employ any person In any ■nner u to BDILER.,BTU
beoome sub)eot to the Worker'Compe tion
DOMPFEBBOR BTu
APPROVALS saWTUPE
VENTILATION SYSTBA
NOTICE TO AP ICA T: IT, r makl g this Certificate of ROUGH
Examptk-'you should beccOm to the Workers'Compensation EVAPORATfVE COOLER
provlslons Of the Leber Code, you must forthrrtth oomply with such Rpt
provisions or this permit shall be deemed revoked. FURNACE F W
LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATION
I hereby aMrm that I am licensed under provisions of Chapter B SUSPEND UNIT
(commencing with Section 1000) of Division 3 of the Business and HEATER Wei i
Professions Code,and my license Is In full force and effect.
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Lk�rre Number Lb.Claw 3 _ IL
.
Corttrador 14 Aid' D.1 �
0..
❑ I am exempt under Hao. Plan check fee
B.sP.C.for thio reason PERMIT ISSUING FEE S O
Dem TOTAL FEE V
ACCT.i OW.
Slgnatu re
ONR ER43UILDER DECLARATION Pty CHECK APPLCANT
3303 rt�f� l lu• Z
I hereby affirm that I am exempt from the Contractors License Lew NAME , 1 I'f FSI
for the following reason (Section 7031.5, Business and Profeesiom
tea): ADDRESS TOTAL 1 IS 20
❑ I, as owner of the property, or my employees with wages I/•.t� �tt, i �r
as their sole compensation, will do the work and the CITY TEL NO. l�TECK 111.20
structure Is not Intended or offered for sale (Healon 7044,
Business and Professions Code). OWNER l� .131-1
❑ I, ae owner of the property, am exclueively contracting MAIL
with licensed contractors to construct'the project (Seo- ADDRESS rY,�tYlt��a�ni t 7r�I
tion 7044, Business and Profeeslors Code). CITY TEL WD—CERN 6/20 94
I CONSTRUCTION LENDING AGENCYfsr
I hereby aff1rm that there Is a construction lending a ehcy for , � i "T"�
the performance of the work for which this permit Is Issued T�
(Sec.3007, CIv.C.). AWY
ADDRESS
Lenders Name
CITY TEL J
Landers Address STATE LIC.
I certify that I have read this application and state that the above LICBN3E No. CLASS
1rrkx hari)n is corned. I agree to oomply with all Courrty ordinances
and 8tete 7r]
reiaifn to �`g
conatruotlon,and hereby authortro
repreeenof enter upon the above-mentioned
nep SEE REVER88 FOR EXPLANATORY LANGUAGE
OFDATE