HomeMy Public PortalAbout4928 GLICKMAN AVE_Mechanical__I
WORKEF OPENSATION DECLARATION 20-0046 DPW 9189
76A364C Al _KATION FOR PERMIT LINE GREE
I hereby affirm that a certificate of consent to self insure,
or a certificate of Worker 5 Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING
copy thereof(pec. ¢Q ab.C.)
we-
Policy No. COmpany COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
Certified copy is hereby furnished.
Certified co y g Inspection is filed with the count building FOR APPLICANT TO FILL IN BUILDING
department. (PRINT OR TYPE ONLY) ADDRESS
Date 72- Applicant - S.� �i�N'r/T/yv' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY r �_
C RTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
CROSS ST. f;
COMPENSATION INSURANCE G�G.�f=/�
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($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as toBOILER,BTU
become subject to the Workers' Compensation Laws.
COMPRESSOR,BTU
APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH ,.
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER _
-provisions of the Labor Code, you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. / FURNACE: FAUNGRAVITY sJ� VALIDATION
LICENSED CONTRACTORS DECLARATION ( FLOOR BTU
'I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT
(commencing with Section 7000) of Division 3 Of the Business and HEATER: WALL
Professions Code, and my license is in full force and effect.
License Number 3 7P Lic.Class. G
1Z
Contractor
y��M�G�1l4NP �� re 0
❑ I am exempt under Sec. Plan Check fee V
B.&P.C.for this reason PERMIT ISSUING FEE$ _ _
Date: TOTAL FEE - ^-- b
OP Signature ®-
PLAN CHECK APPLICANT
OWNER-BUILDER DECLARATION r w W y U)
Z
I hereby affirm that 1 am exempt from the Contractor's License Law NAME e_ MgFe -I A^.0,!' Gp ® _
for the following reason (Section 7031.5, Business and Professions
Code): _:...,
❑ I, as owner of the property, or my employees with wages ADDRESS 12!1,— BC S,A N�4 G4,A lye �j 77 �..
as their sole compensation, will do the work and the CITY t!krz- ,9y f) TEL.NO. �70•_ _??
structure is not intended or offered for sale (Section 7044, T'
Business and Professions Code). OWNER �IV A/ leoA.lA
❑ _ .�.. ... n;..; ...
I, as owner of the property, am exclusively contracting MAIL fat I"`
with licensed contractors to construct the project (Sec- ADDRESS ` �e,04�-Of 5 � T/�
tion 7044, Business and Professions Code). CITY (�� L�fJ® TEL.NO.
CONSTRUCTION LENDING AGENCY !
I hereby affirm that there is a construction lending agency for CONTRACTOR g?� ��
the performance of the work for which this permit Is issued e I��C�/�N/ �-
(Sec.3097, Civ. C.).
ADDRESS 'Z S— , A NT1 G�l��ra- < I
Lender's Name
CITY A e AC�1 OZ. TEL.NO. 57 r 7
Lender's Address STATE Gn LIC.
I certify that I have read this application and state that the above LICENSE NO. 1(- j 7 CLASS �.
information is correct. I agree to comply with all County Ordinances
andState aws relating to building construction,and hereby authorize
represe ti es of this ounty to enter upon the above-mentioned
pro pe f s c rpesee✓� SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATURE OF APPLI ANT OR AGENT DfrE