Loading...
HomeMy Public PortalAbout5006 GLICKMAN AVE_Mechanical__ WORKE ' MPENSATIONDECLARATION 20-0046 DPW 9/89 G EW I hereby affirm that a certificate of consent to self insure, 76A364C AICi4TlOfel FOR PERMIT LIME or a certificate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING copy thereof(Sec.3800 Lab.C.) 'd Policy No. f V ivz�'�"I nilany (UGAG-Gr�P^ COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV. ❑ Certified copy is hereby furnished. BUILDING Certified copy is filed with the county building inspection FOR A PLT IC TNT TOOLFILL IN ADDRESS t;``f Ali � � depart) ent. Date Applicant e r sea9���7l;;el NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST. �v L i G } f✓5�} COMPENSATION INSURANCE 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($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO. PROCESSED BY I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to BOILER,BTU �7r_ become subject to the Workers' Compensation Laws. COMPRESSOR,BTU v D(� 23 7-3 APPROVALS DATE INSPECTOR'S SIGNATURE Date Applicant VENTILATION SYSTEM NOTICE TO APPLICANT: If, after making this Certificate of ROUGH Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER provisions of the Labor Code, you must forthwith comply with such FINAL r 1 provisions or this permit shall be deemed revoked. / FURNACE: FAU A GRAVITY LICENSED CONTRACTORS DECLARATION FLOOR BTU © '23 /ry VALIDATION I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT (commencing with Section 7000) of Division 3 of the Business and HEATER: WALL Professions Code,and my license is in full force and effect. License Number Lic.Class Zd l C�. Contractor e ❑ I am exempt under Sec. t Plan Check fee cc B.&P.C.for this reason PERMIT ISSUING FEE$ Ztf,. 7Ej� 17— Date: TOTAL FEE LU � Signature CL OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT Z I hereby affirm that I am exempt from the Contractor's License Law NAME �� �/k �A- for the following reason (Section 7031.5, Business and Professions Cd C,� __ _ Code): ❑ I, as owner of the property, or my employees with wages ADDRESS �,r- 5 ��� as their sole compensation, will do the work and the CITY 4������ poiTEL.NO. S7Yr/?Tf structure is not intended or offered for sale (Section 7044, T w A. Business and Professions Code). OWNER ❑ 1, as owner of the property, am exclusively contracting MAIL ^ with licensed contractors to construct the project (Sec- ADDRESS ULcL S' f=LD�./�!L Y / T(aS ,"( °'•,;, ; ,.JI_I tion 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY CITY TEL.NO. TEL. I hereby affirm that there is a construction.lending agency for CONTRACTOR the performance of the work for which this permit Is issued (Sec.3097,Civ. C.). ADDRESS P�jr IN 5.Rn/rfifl �G/4 Lender's Name 1` CITY l'7,? ✓;I�97/i? ��G'O,&L.NO. Lender's Address STATELIC. r �+ I certify that I have read this application and state that the above LICENSE NO. 66 3 e CLASS 2 information is correct. I agree to comply with all County ordinances and State laws elating to building construction,and hereby authorize representatt/e�of this unty to enter upon the above-mentioned property fo - ect'o p poses. SEE REVERSE FOR EXPLANATORY LANGUAGE DA L�__ SIGNAVfO OF APPLIC T OR AGENT DTE