HomeMy Public PortalAbout4960 GLICKMAN AVE_Mechanical__ ION
DECLARATI
WOthat certificate
of consent to 76A346DPW9/89 A�WICA►TION FOR PERMIT LI E GREED
70-00 4C
I hereby affirm that 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.)
�
cy No. � G (3r pany Gf>Gi)�n/�.HGG COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
F1� Certified copy is hereby furnished.
BUILDING
L`1 Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN ADDRESS /y/A,�
depart nt. (PRINT OR TYPE ONLY)
Date i �J Applicant ` 5 G� NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY Ira
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST. GiDW,,e .�4Z05;A
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($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit 3
is issued, I shall not employ any person in any manner so as to BOILER,BTU
become subject to the Workers' Compensation Laws.
COMPRESSOR,BTU
APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL -
provisions or this permit shall be deemed revoked., / FURNACE: FAURAVIIY 2
LICENSED CONTRACTORS DECLARATION ( FLOOR BTU e'6 VALIDATION U
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED-UNIT-
(commencing
USPENDED UNIT(commencing with Section 7000) of Division 3 of the Business and WALL
Professions Code,and my license is in full force and effect.
to rNL°'TT
//�
License Numbery� �'��� Lia Z®
Class �
Contractor -Date
❑ I am exempt under Sec. Plan Check fee 0
B.&P.C.for this reason PERMIT ISSUING FEE$
Date: 1.TOTAL FEE w
Signature a_
OWNER-BUILDER DECLARATION CD
PLAN CHECK APPLICANT
Z
I hereby affirm that I am exempt from the Contractor's License Law NAME ���y e-C--
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 CITYTEL.NO.
structure is not intended or offered for sale (Section 7044, A��
Business and Professions Code). OWNER
❑ S TA�7'S /°`✓%%',�' f✓�?//�'^`',9�-- : .:_ray.. _,._.. . T _ -
1, as owner of the property, am exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRESS f e (�A[Pd j g.. l _•'• -• ='='
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY Z Jr� TEL.NO.
I hereby affirm that there is a construction lending agency for CONTRACTOR
the performance of the work for which this permit Is issued (� M ��q/✓J( L L�i"i
(Sec. 3097,Civ. C.).
ADDRESS a 14
••_ '_•-_ ""'' '' '_`
Lender's Name - j y `U
CITY �}��/a ?(___gTEL.NO. -
1 Lender's Address // 7 7
I certify that I have read this application and state that the above LICENSE NO. L J/ G LIC
information is correct. I agree to comply with all County ordinances
and Stat I s relating to building construction,and hereby authorize
repre n � es of th's County to enter upon the above-mentioned
prop rt r'n c Ion purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
SIG ATURE OF APP (CANT OR AGENT DATE