HomeMy Public PortalAbout4950 GLICKMAN AVE_Mechanical__ WOthat MPENSATIOe of consent to 76A346DPW9/89 A _ICATI®N FOR PERMIT LIME GREE_ _
76A364C
I hereby affirm that ! a certificate of consent to self insure, �•y
or a certificate of IN-- . Compensation Insurance, or a certified HEATING-VENTILATING -AIR CONDITIONING
cop there S 09 Lab. C.)
Policy No. Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
Certified copy is hereby furnished.
91 Certified co is filed with the county building inspection FOR APPLICANT TO FILL IN BUILDING . �� .� M��
PY 9 P ADDRESS --
department. (PRINT OR TYPE ONLY)
Date L Applicant - 7/rYY N0. LOCALITY 9 �_
TYPE OF APPLIANCE OR EQUIPMENT FEE /
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
CROSS ST.
COMPENSATION INSURANCE ABSORPTION UNIT,BTU
SSOR
(This section need not be completed if the work involved by the MAP EBOOK PAGE PARCEL
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU G�s2�2
become subject to the Workers'Compensation Laws. ` J
COMPRESSOR,BTU J
APPROVALS DATE INSPECT 'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER '
provisions of the Labor Code, you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. d FURNACE: FAU _ RAVjTY
LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 HEATERSUSPENDED UNIT
:
(commencing with Section 7000) of Division 3 of the Business and WALL
Professions Code, and my license is in full force and effect.
License Number 63 7 P 747 Lic.Class
Contractor �$B "-'-'• U
❑ Plan check fee _ - -:'-
I am exempt under Sec.
B.&P.C.for this reason PERMIT ISSUING FEE$ 76 _ ? !w'•' ® ,I
Date: TOTAL FEE-
Signature
EE LU
0
Signature
PLAN CHECK APPLICANT •—- .,. _. Z
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law NAME
for the following reason (Section 7031.5, Business and Professions ,� �✓ &HAN1 eq Z
Code): ADDRESS Z ji4+�P C� i2 e%v
❑ 1, as owner of the property, or my employees with wages
as their sole compensation, will do the work and the CITY �G��' TEL.NO.
structure is not intended or offered for sale (Section 7044, A TT _" H.
Business and Professions Code). OWNER 57
❑ I, as owner of the property, am exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRESS 4i� 7 r �L��/�2 S ; 1B
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY L� �p 7TEL.NO.
I hereby affirm that there is a construction lending agency for CONTRACTOR ,
I performance of the work for which this permit Is issued �(� f/t�Gj�/}s�/ C C_
(Sec.3097,Civ. C.).
ADDRESS /,� ^1 G•�I P-53,
Lender's Name
CITY AR—`.A'o TEL.NO. J5747 -,7751dx
Lender's Address STATELIC.
I certify that I have read this application and state that the above LICENSE NO. 637,072 CLASS
information is correct. I agree to comply with all County ordinances
and State relating to building construction,and hereby authorize
represe t' es of thig County to enter upon the above-mentioned
proper s i - SEE REVERSE FOR EXPLANATORY LANGUAGE
II SIGNAT E OF APPLIC NT OR AGENT !DATE_