HomeMy Public PortalAbout4938 GLICKMAN AVE_Mechanical__ WORKS e a certificate
DECLARATION 76A346DPW9189 q LIGATION FOR PERMIT LI E GRE _ _
76A364C
I hereby affirm the e 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. 3800 Lab.C.)
Pl
r_1.
cy No.kl'f 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 BUILDING
ADDRESS a
department. (PRINT OR TYPE ONLY)
Date 2—1 1111 Applicant5�`jSr�NTf7'HC1 LOCALITY (f
` NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS'
CROSSS TGse A Z U 5/-4
COMPENSATION INSURANCE ABSORPTION UNIT,BTU
(This section need not be completed if the work involved by the MAPESSOR BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to I BOILER,BTU
��become subject to the Workers' Compensation Laws. // '
COMPRESSOR,BTU�l�� � �3 / �J
APPROVALS DATE INSPE TOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH 6
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor'Code, you must forthwith comply with such FINAL d L t
provisions or this permit shall be deemed revoked. i FURNACE: FAU t^ GRAVITY �f
LICENSED CONTRACTORS DECLARATION / FLOOR BTU LO / L-� VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT
(commencing with Section 7000) of Division 3 of the Business and HEATER: WALL
Professions Code, and my license is in full force and effect.
o ,
License Number � J z-7 0 71 Lic.Class C_
Contractor MFr �PyAy9 Date � � �
❑ Plan check fee
I am exempt under Sec.
B.&P.C.for this reason PERMIT ISSUING FEE$ 73' _••• - "'
Date: TOTAL FEELU
Signature •: ....`:
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT "' U)
I hereby affirm that I am exempt from the Contractor's License Law NAME
for the following reason (Section 7031.5, Business and Professions & feCHA Aj/G C.— L'r✓ t �I:`I°I•,
Code): `.4!•�['P.3�. --
❑ I, as owner of the property, or my employees'with wages
ADDRESS pct tom^ P� s�.ny G�A �� �j
as their sole compensation, will do the work and the CITY A A--,q 6>/ q TEL.NO. 7�
structure is not intended or offered for sale (Section 7044, / 7 _._.._ .....,.__.
Business and Professions Code). OWNER tr A P—t s
❑ I, as owner of the property, am exclusively contracting MAIL �f
with licensed contractors to construct the project (Sec- ADDRESS r,4 �j s %" It-61Jf51-7
tion 7044, Business and Professions Code). CITYG,�®�� TEL.NO.
CONSTRUCTION LENDING AGENCY
Ihereby affirm that there is a construction lending agency for �� ,
the performance of the work for which this permit Is issued CONTRACTOR Y\e Nl �AHA
(Sec.3097, Civ.C.).
ADDRESS !2 5 fi r .r+ i�AJ_rA �✓-L o'�/� y%f ' /
Lender's Name f,
CITY A a e A 01,9 TEL.NO. Sir 7 75�
Lender's Address STATE G LIC. T
I certify that I have read this application and state that the above LICENSE NO. 637 G 7 / CLASS
information is cc rect. I agree to comply with all County ordinances
and State laws elating to b�nty
g construction,and hereby authorize
representaiiv ppof this
@Coo enter upon the above-mentioned
property/`for Ins ectio p s SEE REVERSE FOR EXPLANATORY LANGUAGE
/ C//^/ll/ .
SIGNATOWOF APPLICANT 9A AGENT DATE