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Home My Public Portal About4956 GLICKMAN AVE_Mechanical__ ION DECLARATI WORKE MPENSATate of consent to 76A346DPW9/89 AWICATION FOR PERMIT LI TE GREE 70-00 4C I hereby affirm that a certificate of consent to self insure, or a certificate of 'or er's Compensation Insurance, or a certified HEATING -VENTILATING-AIR CONDITIONING copy thereof(Sec.3800 Lab. C.) Policy NO. I 0 Cdr4any � /� �FT�L COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV. Certified copy is hereby furnished. 10 Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN BUILDING ADDRESS depart ent. (PRINT OR TYPE ONLY) Date �� Applicant G i�l��°`f//�/��r� LOCALITY (� N0. TYPE OF APPLIANCE OR EQUIPMENT FEE NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST. tot—j i 2 A 2 U SA- COMPENSATION INSURANCE 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($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO. PROCESSED BY I certify that in the performance of the work for which this permit is issued; I shall not employ any person in any manner so as to BOILER,BTU become subject to the Workers' Compensation Laws. 1� COMPRESSOR,BTU 2 J APPROVALS DATE INSPECTOR'S SIGNATURE Date Applicant VENTILATION SYSTEM NOTICE TO APPLICANT: If, after making this Certificate of ROUGH A4? Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER provisions of the Labor Code, you must forthwith comply with such FINAL provisions or this permit shall be deemed revoked. FURNACE: FAU RA ITY, '2 n� VALIDATION LICENSED CONTRACTORS DECLARATION FLOOR BTU 66�� 7 I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT (commencing with Section 7000) of Division 3 of the Business and HEATER: WALL Professions Code,and my license is in full force and effect. J� AIL-�7$ JU7LE7-S Z / License Number A.2., / ,�, 71 Lic.Class 62-0 54 Contractor ate ❑ I am exempt under Sec. Plan Check fee B.&P.C.for this reason PERMIT ISSUING FEE$ Zl f �7j Date: TOTAL FEE �/3 3 R � Signature CL PLAN CHECK APPLICANT CD OWNER-BUILDER DECLARATION Z I hereby affirm that I am exempt from the Contractor's License Law NAME f/ M��yAN�� G� 011.for the following reason (Section 7031.5, Business and Professions C- ❑Code): ADDRESS ) 2 d ��/� GCla2�! y; r �� I, as owner of the property, or my employees with wages as their sole compensation, will do the work and the CITY C1,9 J_ TEL.NO. j 7�r �� structure is not intended or offered for sale (Section 7044, A ke'A0 f l Business and Professions Code). OWNER S TAA ZTr. /^/r,'oeNA J-/--^/A L _„ ❑ I, as owner of the property, am exclusively contracting _ -• _ L' MAIL /' �!/! with licensed contractors to construct the project (Sec- ADDRESS q- �� L C,C��'/2 S�" T7 T�� tion 7044, Business and Professions Code). CITY /—A- 7 TEL.NO. CONSTRUCTION LENDING AGENCY y - I hereby affirm that there is a construction lending agency for CONTRACTOR the performance of the work for which this permit Is issued / L M(— PYA^-11 C%4 C (Sec.3097, Civ. C.). a ADDRESS -„- Lender's Name _ - ^� CITY A e C A '9 p i4- Ito D 6TEL.NO. f 7 ''7/ Lender's Address STATE LIC. I certify that I have read this application and state that the above LICENSE NO. 6 370 2 CLASS Z O information is correct. I agree to comply with all County ordinances and State I w relating to building construction,and hereby authorize rep is of thi County to enter upon the above-mentioned proper 6 spec!' n purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE SIGNATURE OF APP CANTOR AGENT DTE