HomeMy Public PortalAbout9514 GARIBALDI AVE_Mechanical__ W°` 8COMPENSATION D I�n`°o' �°°"°P'"°/�° APPLICATION FOR PERMIT LrAAE . GREEN,
I hereby affirm that I have a certificate of oonaent to self Insure,
or a certificate of Worker's Compensation Insurance, or a certified -HEATING'-VENTILATING-AIR CONDITIONING
Lab.C.)
n ry COUNTY OF LOS ANGELES DEPT OF PUBUC WORKS BUILDING AND SAFETY DIV.
Cer"ad copy to hereby furnished.
Certified copy Is feed with bufidirp FOR APPLICANT TO FILL IN Ut-DI.8
(PRM OR TYPE ONLY)
C
LOCALITY
Date NO. TYPE OF APPLIANCE OR EOUIPYENT FEE
CEFMFICATE OF EXEAIPT}ON FROM WORKERS' NST
C1a088 8T. -
COMPENSATION INSURANCE Ag9ORpT1 N UNIT BTU ASSESSOR
(Thla section need not be completed Hee twork Invotved by the MAP BOOK PAGE PAACg
parmtt Is for one hundred doRm(71100)or lees.) AIR HANDLING UNIT CFiI
oar wa moXMeso 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 sou to BTU
become eubject.to the Workers' Compensation Lars. D
el U rasRovAts an sura WKWTU e
Date Appfot" VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this CertRloate of ROUGH
Exemption,you should become subject to the Workers'Compermadan EVAPORATE COOLER
provisions of the Labor Code, you must forthwith comply with such F1NAL
provisions or thla permit shall be deemed revoked. FURNACE FAu G �pTl
LIVALIDATION
LICENSED CONTRACTORS DECLARATION FLOOR BTU O
I hereby affirm that I am licensed under provisions of Chapter Q HEATER: SUSPENDED UNIT.
(commencing with Section 7000) of Division 3 of the Business and WAL
Profeeslons Code,and mmyy Roennse Is In full force end etfecL
Lk ertse N u mbar pave S c�
Cont mctorDete d
.❑ 1.exempt Sec. Plan check fee
B.BP.C.for this reason PERMIT ISSUING FEE$ O
Dole: TOTAL FEE U
` dftnature LU
a
PLAN CHECK APPLICANT co
OWNER-BUILDER DECLARATION z
I hereby affirm that I am exempt from the Contractors Llosnae Law NAVE
for the following reason (Section 7031.6, Business and Professions S ASf�r
, rt•T.T
Code): ADDco
I, ae owner of the property, or my employees with wages 33D7 tv•OrI.
■s theft able compensation, will do the work and the CITY TEL NO. i T
i structure Is not Intended or offered for sale (Section 7044, .1 1
Business end Professions Code). OWNER { ��
Fj I, as owner of the property, am exclusively contracting TOTAL
NAIL La.�y�
with licensed contractors to construct the project (Seo- ADDRESS CWCY, tCI W
tion 7044, Business and Professions Code). I
CONSTAUENIS
CTtON LENDING AGENCY CITY T _NO �' .00
I herebyy affirm that there Is a construction lending agency for
the pertormanca of the work for which this permit le Issued OO�TOR r�I
(Sec.3097,Clv. C.). AaDREsa / 000M�y-1 t1 1/19193
Lenders Name 7691 1 AMI D.09
CITY TEL
Lenders Address STATE LIC. �y
I certify that I have read this appffcation and state that the above LICENSE NO.
hrformaifon Is correct I agree to oompty with all Coutrty ordinances
and State laws relating to building consMxy don,and hereby autivrtze
ntatfvee of th Cou to enter upon the above-mentloned
pro a for Irupe n pu REVERSE FOR EXPLANATORY LANGUAGE
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