HomeMy Public PortalAbout5002 GLICKMAN AVE_Mechanical__ WORKEIIWPENSATIONDECLARATION 20-0046 DPW 9/89 A[�LICATION FOR PERMIT LIE GREED
I hereby affirm that a certificate of consent to self insure, 76A364C
or a certificate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING -AIR CONDITIONING
copy thereof(Sec.3800 Lab.C.)
"woe_ �to�
Policy No. C1/6 Company Lac �E� �G�� COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
❑ Certified copy is hereby furnished.
® Certified copy is filed with the count buildingInspection - FOR APPLICANT TO FILL IN BUILDING L Gr
depart Ent. y (PRINT OR TYPE ONLY) ADDRESS _�J- s �f�f7/� �� 4v,-e—
Date ApplicantLOCALITY
Lp Z/5 A�7 j �l/L'✓`1 NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
NEARECERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST . LeJGJ�/L /a ZL'Sf}
COMPENSATION INSURANCE ABSORPTION UNIT,BTU
(This section need not be completed if the work involved by the MAPESSOR BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit J^
is issued, I shall not employ any person in any manner so as toBOILER,BTU f'Q �y� �= - '`�
become subject to the Workers'Compensation Laws. F =.2,
COMPRESSOR,BTU b�
APPROVALS 'DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. / FURNACE: FAUGRAVITY r
LICENSED CONTRACTORS DECLARATION G FLOOR BTU rp o-c 2? '75 VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT
(commencing with Section 7000) of Division 3 of the Business and HEATER: WALL
Professions Code, and my license is in full force and effect.
License Number 6 3 7e-77 Lic.Class C Lc�)
Contractor M�CN�N r G C'l5ate g pool0
EJ Plan check fee
I am exempt under Sec.
B.&P.C.for this reason PERMIT ISSUING FEE$
U
Date: TOTAL FEE ��9j ?�� UJ
Signature 03
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License Law NAME
for the following,reason (Section 7031.5, Business and Professions
Code): ADDRESS
❑ I, as owner of the property, or my employees with wages C���� 5H"� ��� L/�I�ff S%+ �
as their sole compensation, will do the work and the CITY �'f(LG'-� a//�D�TEL.NO. �� , ;7 7X?
structure is not intended or offered for sale (Section 7044,
Business and Professions Code). OWNER ^/14EJ - _
I, as owner of the property, am exclusively contracting MAIL -
with licensed contractors to construct the project (Sec- ADDRESSSL
tion 7044, Business and Professions Code). %-J.',•, :_'<
CONSTRUCTION LENDING AGENCY CITY 'L A- t C / 7 TEL.NO.
I hereby affirm that there is a construction lending agency for CONTRACTOR
I he performance of the work for which this permit Is issued l� 0`7/ /v"/(L✓1 L C ,
(Sec.3097,Civ.C.). �(
ADDRESS Iz'� '7� CL�,�-� �� -
aa-
Lender's Name
CITY AR TEL.NO.
Lender's Address STATE LIC.
I certify that I have read this application and state that the above LICENSE NO. 63 D'� CLASS cf_' 2
information is correct. I agree to comply with all County ordinances
and State law relating to building construction,and hereby authorize
represen i s of this ounty to enter upon the above-mentioned
propert f n p rpose SEE REVERSE FOR EXPLANATORY LANGUAGE
I / ,
SIGNATURE OF APPLIC NT OR AGENT DATE