HomeMy Public PortalAbout9507 GARIBALDI AVE_Mechanical__ WORKERS'COMPENSATION DI- LAR ITION 76.4364c APPLICATION FOR PERMIT
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1 hereby affirm that [ have a certificate of (onse•nt to self C 8'1 2901)
insure or a certificate of Workers'Compensation InSurance,or HEATING-VENTILATING-AIR CONDITIONING
a certified cop} theteof(S c. 38110, Leh C )
-,�,•. ..r I -ri: -
Policy No. Company__.
Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with the county buitdin�inspection
department. ; FOR APPLICANT TO FILL IN BUILDING j '': 1 1 k
r
Date Applicant (PRINT OR TYPE ONLY) ADDRESS " 1
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L
- r.
--�--- - LOCALITY
CERTIFICATE OF EXEMPTION FROM WOR KI:RS' NO, TYPE O� APPLIANCE OR EQUIPMENT FEE —__ _ _ _ _—.__-_.___ CLO
COMPENSATION INSURANCE - -- NEAREST U
CROSS ST. JJ
(This section need not be completed if the work involved IABSORPTION UNIT, BTU- LU
by the permit is for one hundred dollars (SIO(i) or less.). _-- DISTRICT NO, PROC Eo _J
AIR HANDLING UNIT,CFM_. i't 5 LL
1 certify that in the l,terformai ce of the wvek Lir which this _ _ � i� � �
permit is issued, [ shall not employ am person in any manner �� _ }
so as to become subject to the Workcr.' Compensation Laws. BOILER, BTU—
APPROVALS DATE INSPECTOR'S SIGNATURE
Date <lpplicantBTU f- - -- 1 --- cc
-----_-_- COMPRESSOR, -_-�
ROUGH 0
NOTICE TO APPLICANT: If, after making this t ,rtifieiu of !VENTILATION SYSTEM
Exemption, should become subject to the '.L'orkers' __ - _ -- __----__-- FINAL M
Compensation provisions of the I-ahor Code, you must forth W
EVAPORATIVE COOLER VALIDATION
with comply with such provisions Or this permit shall'be --- --- --- i
deemed revoked.
(,FURNACE: FAU-_ GRAVITY i
LICENSED CONTRAC'TOR�:, t; C', ' N' FLOOR BTU__— --
I hereby affirm that I am lice i.,.. u:r j HEATER: SUSPENME , t.N!T
9 (commencing with Section L I- n WALL
ness and Professions Code, i a I I,,,
effect.
License Number__ Li
j
Class__
a'
r'
Contractor ----...� Date
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I am exempt from the Iiccnsing requirements as I am n --_-L— _ -
licensed architect or a registered professional engineer PIT check fee 25% of above.
acting in my professional capacity (Section 7051. Bus- ----- ------- -
iness and Professions Code). i PERMIT ISSUING FEE $ sr ,
Lic.or Keg.No.
— Trate ____.-.-- _
TOTAL FEE
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt fro r, Oi. NAME
License Law for the follow.ng reaso t
ness and Professions Code). ADDRESS t-
1, as owner of the property, wiii do tna
structure is not intended of o`teted I, CITv TEL NO
7044, Business and Professions C ,d�'. -
O OWNER
i, as owner of the property. tr :.cis
„
t e-n,ry }s• + ,.
with licensed contractor, to 1. MAIL
is
(Section 7044, Business and L'ce,ti„ice;? eel. ADDRESS •
CONSTRUCTION LENDING Al;VN ), CITY TEL. NO.
C.
cunsfrucuon lending t �a
I hereby affirm that there is u - ----;T___--_ __- —
for the performance of the work for which this permit CONTRACTOR
issued (Sec. 3097,Civ.C).
Lender's Name-------, ._--_- ADDRESS
Lender's Addressrrf
-----..-.------------- CITY TEL. N O. .. .: .,I It>i,:+j
I certify that I have read this ipp`i tion and state tl t tNie STATE LIC.
above information incorrect. I etre(- o, coinple t\ith all C cur i, I LICENSE NO CLASS
ordinances and State laws regulatitrg L-Icating. Ventilating•{
Air Conditioning, and hereby auth,xiie of I'li, SEF: REVI`_RSi, IY)R 1:XPLANA'1'OR`r LANGUAGE:
County: to enter upon the ahove-mentioned nrol'ert,• to,
inspection purposes,
Signature of Permittee --' ----