HomeMy Public PortalAbout9008 GARIBALDI AVE_Mechanical__ WGFUCE-T'S COMPENSATION DECLARATION 20-0048 DPW 9/99
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I hereby�tfirm that I have a certl}Icate of consent to eel} Insure, APPLICATION FOR PERMIT LIME GREEN
cr a certtfIcate.of workers Compensation Insurance, or a certlfled HEATING-VENTILATING-AIR GONDMONING
oopythersof(Sec.3800 lab.C.)
pofloy No. Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
❑ CerdW copy Is hereby tum}shed.
❑ CeraW copy is riled wfth line county buldbV.Inspaallon FOR APPLICANT TO FILL IN BUI U �I
FHIWr OR TYPE ONLY) ADDRESS
Date ApQ+bent LOCALITY
NEAREST
NO. TYPE OF APPt�ANCE OR EOUtPMEYr F�
CERTIFICATE OF-EXEMPT"FROM WOPXEP ' ST.
COMPENSATION INSURANCE AgepgpT"UNIT BTU
(This soctfon need not be comphted if the work Involved by the A88E880R
MAP BOOfC PAGE � PARCH
penult Is for one hundred dollars(tt00)or has.) AIR HAADLD40 UNIT CFM
DfTfCT Na aY
I oerttfy that In the performance of the work for which t Is pbrmlt
Is Issued, I shall not employ any person I any man as to BOLEP,BTU
beoo abject to the Workers' Co n
COY BTU
uPPrnvKs oxn eseATur
lllfDate VENTILATION SYSTEM
NOT E TO APP ICA : I1, makln le Certlflcate of FKX)W Z
you should beoon-Fe&m6fact to the W 'Comperuflon EVAPORATIVE COOLED
provisions of the Labor Code, you must forthwcomply with such FINAL
ith 1 -411
provblons or this permit shall be deemed revoked. FURNACE: FAU
UCENSED CONT ACTOBS DEC-L ,TK>N MZOR BTU VALIDAT ON
I hereby affirm that I em Iloensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
(oommencing with Seotlon 7000) of DNtalon 3 of the Business and W
Profeeatono Code,and my[Ice-nee Is In full force and aMW.
License Number Lk-Claes�—
Ca AG S lr' a
❑ m I eexempt under Seo. Plan check fee
B.BP.C.for thio reason PERMIT ISSUING FEE$ 0
Data. a
TOTAL FEE " W
ACCT.T o-
OWNER-BUII-DERDCLARATION PLAN CREp(APPLkANT � � 118.2D Z
E
I hereby aMrm.that I am exempt from the Contractor's License Lew NAME
for the following reason (Spatlon 7031.6, Buslneea and Profeealons , 1 ITt�11-
E h7
Cade): ADDRESS TOTAL 113 _ ?ID
❑ T, es owner of the property, or my employees with wages
as their sole compensation, wilt do the work and the CITY TEL f NO. y EU 11 3
structure Is not Intended or offered for sale (Section 7044, �•uI�ww���I.�� r�r
Business end Professlons Code). OWNER +.d-Its'Tl� .CrLI
❑ I, as owner of the property, em exclusively contracting MAIL
with licensed contraotors to construct the project (Seo- ADDRESS �y�,y�_�y-fit �n Oi
tion 7044, Buainess and Professions Code). CITY TEL l �_ LXM-0001 5/20/94
CONSTRUCTION LENDLNO AeENCY � 1 AM u••AI
1 hereby affirm that there Is a construction lending a enoy for ,
the pertormonoe of the work for which this permit is Issued
(Seo.3097,Ctv.C.).
ADDRESS
Lenders Name
CfTYSN kv
TEL-
Lenders/lddreae STATEUC.
I certify that I have read this application and state that the above LICL]•lSE NO. CLASS
Information is correct- I agree to ry with all County ordlnanoes
X
P59
,and hereby aut xxtze
th above-mentioned
SEES REVERSE FOR EXPLANATORY LANWAGE
Tupe OF Al DAIrw
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