HomeMy Public PortalAbout5000 GLICKMAN AVE_Mechanical__ DECLARATI
WORKEFMMPENSATION
ate of consent to 76A346DPW9/89 A SLICATION FOR PERMIT L� E GRE ED
76A364C !1 /�'� ��1
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.38000 Lab.C.)
Policy No.W f1" Md 0 ` 4ripany L''oL0qE^1 COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
❑ Certified copy is hereby furnished.
® Certified copy is filed with the count building BUILDING 6
depart ent. y g inspection FOR APPLICANT OR TMP TOFILLIN ADDRESS'>UF✓G
LOCALITY
Date' 2 �3 Applicant ` S�f�A�y�y�UNI �� .
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST.
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($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU �U
become subject to the Workers' Compensation Laws.
COMPRESSOR,BTU G CIO
APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after "making this Certificate of ROUGH / „ 7 1-5—
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
k(.gt
provisions of the Labor Code, you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY ?
LICENSED CONTRACTORS DECLARATION FLOOR BTU 10-04� 3 2� VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT
(commencing with Section 7000) of Division 3 of the Business and HEATER: WALL
Professions Code, and my license is in full force and effect.
License Number '7�j? / - r Lic.Class C 2—C)
x:
Contractor KC bate / - t
ElI am exempt under Sec. Plan Check fee
cc
B.&P.C.for this reason PERMIT ISSUING FEE$ tyl�
Date: TOTAL FEE '-P lU
CL
Signature
PLAN CHECK APPLICANT U)
OWNER-BUILDER DECLARATION Z
I hereby affirm that I am exempt from the Contractor's License Law NAME P� Mrn'G�,4,V1 e,4
for the following reason (Section 7031.5, Business and Professions
Code): ADDRESS
❑ I, as owner of the property, or my employees with wages 2 � �'�
as their sole compensation, will do the work and the CITYNO:
structure is not intended or offered for sale (Section 7044,
Business and Professions Code). OWNER S i' ✓� ?E2�°r3'T/��`
❑ I, as owner of the property, am exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRESS�- 5 GGriG✓�/L S`/ "��D
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY L h- 10-0/7 TEL.NO.
I hereby affirm that there is a construction lending agency for CONTRACTOR z �y
the performance of the work for which this permit Is issued Vii' m1 e-1-114/V/L�e—
(Sec.3097,Civ.C.).
ADDRESSl'r"4Nr7A 6, 'GgA
Lender's Name ` A� �7lL 7
CITY f IF ,q �1 G r�L.NO. �/ 7 '�I
Lender's Address STATE LIC.
I certify that I have read this application and state that the above LICENSE NO. (0-37029 CLASS C Z�
information is correct. I agree to comply with all County ordinances
A
ting to building construction,and hereby authorize
this County to enter upon the above-mentioned
ion purp es. SEE REVERSE FOR EXPLANATORY LANGUAGE
NT OR AGENT DATE