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Home My Public Portal About4962 GLICKMAN AVE_Mechanical__ WORKEPENSATIONDECLARATION 20-000 046 DPW 9/89 AIC�4TION FOR PERMIT LIE GRE[or 70 4C I herebyaffirm that a certificate of consent to self insureM , a certificate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING copy thereof(Sec.3800 Lab. C.) Policy NG?UWe- i / C3fnpany �Ot, rrL1= 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 ADDRESS Z depa mCtent. (PRINT OR TYPE ONLY) �`-�� _� w✓� Date Z / Applicant �%` ' /� ��i�/d� LOCALITY iy N0. TYPE OF APPLIANCE OR EQUIPMENT FEE 1 CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST CROSS ST. LPGJ/f fL ,iQ ZCJ S/9 COMPENSATION INSURANCE ABSORPTION UNIT,BTU This section need not be completed if the work involved ASSESSOR ( b P Y the MAP BOOK PAGE PARCEL , permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO. PROCESSED BY I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to BOILER,BTU become subject to the Workers' Compensation Laws. d� B00 27 l d COMPRESSOR,BTU 7 APPROVALS DATE INSPECTOR'S SIGNATURE Date Applicant VENTILATION SYSTEM NOTICE TO APPLICANT: If, after making this Certificate of ROUGH Z, Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER provisions of the Labor Code, you must forthwith comply with such FINAL provisions or this permit shall be deemed revoked. / FURNACE: FAU GRAVITY LICENSED CONTRACTORS DECLARATION ( FLOOR BTU 00 O©�7 23 7) VALIDATION I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT (commencing with Section 7000) of Division 3 of the Business and HEATER: WALL Professions Code, and my license is in full force and effect. I 11 �,w�r 7s 4 �vTC.f�s �Z 13 License Number / 23 70 71 Lic.Class Zd Contractor K 9e-Gf16t"2N_12 abate ) 0 ❑ I am exempt under Sec. Plan Check fee B.&P.C.for this reason PERMIT ISSUING FEE$ y.1l Date: TOTAL FEE Signature Q PLAN CHECK APPLICANT (i7 OWNER-BUILDER DECLARATION Z I hereby affirm that I am exempt from the Contractor's License Law NAME /-7r'C7c/A I Pin(_ ePj for the following reason (Section 7031.5, Business and Professions Code): Z ADDRESS El1, as owner of the property, or my employees with wages as their sole compensation, will do the work and the CITY p--A G1 Q b TEL.NO. 5 ._ %G� - structure is not intended or offered for sale (Section 7044, Business and Professions Code). OWNER -T�n_T5 I, as owner of the property, am exclusively contracting MAIL '' '`• ' with licensed contractors to construct the project (Sec- ADDRESS �r �t!0f le1Z S T�•'�5 ` ' J._ °'"' tion 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY CIN LA 10617TEL.NO. { --- - I hereby affirm that there is a construction lending agency for CONTRACTOR the performance of the work for which this permit Is issued t�� /'�/j;��gi.1 @�[- �cYi (Sec.3097, Civ.C.). Lender's Name ADDRESS rLG�A1,4 �� V i7. CITY /9 9/0C&EL.NO. Lender's Address STATE , LIC. I certify that I have read this application and state that the above LICENSE NO. 3 7 - CLASS C 20 information is correct. I agree to comply with all County ordinances and State I ws relating to building construction,and hereby authorize repres ves of thCounty to enter upon the above-mentioned prope t f insp c v purposes— SEE REVERSE FOR EXPLANATORY LANGUAGE ATURE SIGNOF APPL CANT OR AGENT DATE