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HomeMy Public PortalAbout4918 GLICKMAN AVE_Mechanical__ ION WORKER 1PENSATate of consent to 76A346DPW9/89 A .ICATION FOR PERMIT LIME , GREE_ _ 76A364C I hereby affirm that I a certificate of consent to self insure, or a certificate of WorKer's Compensation Insurance, or a certified HEATING-'VENTILATING-AIR CONDITIONING ' copy thereof(Sec.3808.C.) it�h/e-�.l41 �LoG� SAG Policy No. Company �� COUNTY OF LOS ANGELES, DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV. ❑ Certified copy is hereby furnished. Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN BUILDREDING �p PJ'j departm nt: (PRINT OR TYPE ONLY) ADSS a3 lTr+ �K�/� DateApplicant 0A^'17/ ?'/VLOCALITY NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST COMPENSATION INSURANCE CROSS ST, lila A�E1 T�' 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($100)or less.) AIR HANDLING UNIT,CFM ' DISTRICT NO. PROCESSED BY I certify that,in the performance of the work for which this permit is issued, I shall not employ.any person in any manner so as to BOILER,BTU , become subject to the Workers' Compensation Laws. . COMPRESSOR',BTU d ®o el APPROVALS DATE INSPECTOR'S SIGNATURE Date Applicant VENTILATION SYSTEM NOTICE TO APPLICANT:' If, after making this Certificate of ROUGH Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER provisions of the Labor,Code, you must forthwith comply with such FINAL provisions or this permit shall be deemed revoked. / FURNACE: FAU R9�TL-- VALIDATION LICENSED CONTRACTORS DECLARATION / FLOOR BTU !6 �6C7 I hereby affirm that I am licensed'under provisions of.Chapter 9 HEATER: SUSPENDED—UNIT— (commencing USPENDED UNIT(commencing with Section 7000) of Division.3 of the Business and WALL Professions Code,and my license is in full force and effect., License Number 9 7/ Lic.Class IL Contractor Li ❑ am exempt,under Sec: Plan check fee (g B.&P.C.for this reason PERMIT ISSUING FEE$ sf 7-j' . 'Fo Date:., TOTAL FEEw .�_.. _ W Signature _ OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT CH A-NI E` � I hereby affirm that I am exempt from the Contractor's License Law NAME for the following reason (Section 7031.5, Business and Professions e' M,0--effAA 40- Code): ADDRESS EJ 0 2 �. �1-F!✓?!1 GL✓ fir-► snT { I, as owner of the property, or my employees with wages as their sole compensation, will do the work and the CITY we ��.� TEL.NO. �/Tr�'�/ "' "" All structure is not intended or offered for sale (Section 7044, Business and Professions Cone). OWNER .4 as s ❑ I, as owner of the property, am exclusively contracting MAIL with licensed contractors to construct the project (Sec- ADDRESS fF Sr GpII�VloA s tion 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY CITY GI� © � TEL.NO. I hereby affirm that there is a construction lending agency for CONTRACTOR , the performance of the work for which this permit Is issued '�- /vf��jr/�'r✓Je,�1 ` e_eJ (Sec.3097,Civ.C.). ADDRESS .� s € S�q N7/� GG iA!�/� S'r ry► Lender's Name_ CITY 112-e—.4 b f td*�- TEL.NO. -5- 7f i7796 L Lender's Address - STATE LIC. T I certify that I have read this application and state that the above LICENSE NO. 7Q 7 CLASS 2 information is correct. I agree'to comply with all County ordinances " and State la4.1 ating to ilding construction,and hereby authorize represent thisCP toe ter upon the above-mentioned property ti u oses. - SEE REVERSE FOR EXPLANATORY LANGUAGE b ? �2�— SIGNATURE OF APPLICANT OR AGENT D E