HomeMy Public PortalAbout4958 GLICKMAN AVE_Mechanical__ ION
WORKE MPENSATate of consent to 76A346DPW9/89 A4WICATION FOR PERMIT LI GRE
70-00 4C
I hereby affirm that a certificate of consent to self insure, �y
EO
or a certificate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING yijlll
copy thereof(Sec.3800 Lab. C.)�.)
PolicyNo. "VC- oln�an L� �ltG-L�
v COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
FJ Certified
Certified copy is hereby furnished. C7
y g inspection FOR APPLICANT TO FILL IN BUILDIN
de artm,copy is filed with the count building PRINT OR TYPE ONLY) ADDRESS` �<—L G� >`7
departure t. (
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Date_Z �7 Applicant �l7f�d NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITYNEARE
CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST.
COMPENSATION INSURANCE ABSORPTION UNIT,BTU
This section need not be completed if the work involved b the ASSESSOR
( P Y� MAP BOOK PAGE PARCEL
permit is for one.hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU �y (/
become subject to the Workers'Compensation Laws.
COMPRESSOR,BTU iG 6
APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM / p
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH C" ^/
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU 0< GRAVITY "3 2! VALIDATION
LICENSED CONTRACTORS,DECLARATION FLOOR BTU 9
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED—UNIT—
(commencing
USPENDED UNIT(commencing with Section 7000) of Division 3 of the Business and HEATER: WALL
Professions Code, and my license is in full force and effect.
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License Number Lic.Class
LL
Contractor
F] Plan check fee
I am exempt under Sec.
B.&P.C.for this reason PERMIT ISSUING FEE$ 7 76
/ U
Date: TOTAL FEE <� '3LU
Signature OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT Z
1 hereby affirm that I am exempt from the Contractor's License Law ' NAME i M��p-I,raNl elf- c� r
for the following reason (Section 7031.5, Business and Professions
Code): ADDRESS
I, as owner of the property, or my employees with wages
as their sole compensation, will do the work and the CITY 'Af eA01A
(r,I? ,TEL.NO.
structure is not intended or offered for sale (Section 7044, r S 7 y
Business and Professions Code). OWNER may'A `r y IF �r J ! a °/A C
F-1 1, as owner of the property„am exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRESS S• �L�'Gl��- ��� ",:
tion 7044, Business and Professions Code). -
CONSTRUCTION LENDING AGENCY CITY L/� �J G 0 7 TEL.NO. I_i
I hereby affirm that there is a construction lending agency for CONTRACTOR
the performance of the work for which this permit Is issued u /'7 61-1At,/Je/-I
(Sec.3097,Civ. C.). _
ADDRESS lj Arr.l
Lender's Name
CITY /TEL NO. Ci a
” OfA p /// 4DET �7/f-
Lender's Address / 7 7
I certify that I have read this application and state that the above LICENSE NO. !� 3 O / rj C ASS e 2—
information
information is correct. I agree to comply with all County ordinances
and State laws elating to building construction,and hereby authorize
represen IV of this C unty to enter upon the above-mentioned
propert�;fl ' pection ur oseS. SEE REVERSE FOR EXPLANATORY LANGUAGE
/
SIGNATURE OF APPLICAYT OR AGENT DATE