HomeMy Public PortalAbout5008 GLICKMAN AVE_Mechanical__ ION
DECLARAT
WOthat certificate
of consent to 76A346DPW9/89 ASLICATION FOR PERMIT L� E GRE[
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.) 7 "d I
Policy No.W 2�)'�V� ol6pany L`J�N FjLG COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
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❑ Certified copy is hereby furnished.
Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN BUILDING
LSS D
departm nt. (PRINT OR TYPE ONLY) ADDR
Date 2- Applicant �% �Al �J�/ T1
/ 14rm LOCALITY
N0. TYPE OF APPLIANCE OR EQUIPMENT FEE NEAREe J
-CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST.T. (,f}WJ5f1L A 2_0 ,q-
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($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU
become subject to the Workers' Compensation Laws. �qQ oQ 7
COMPRESSOR,BTU ° 2� /5-
APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER r
provisions of the Labor Code, you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU VALIDATION
LICENSED CONTRACTORS DECLARATION FLOOR BTU (Jd
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT
(commencing with Section 7000) of Division 3 of the Business and HEATER: WALL
Professions Code, and my license is in full force and effect.
� /I /Ny(��S ti a
License Number 61-17P'71 Lic.Class �LO
i�
Contractor
F] Plan check fee
I am exempt under Sec.
B.&P.C.for this reason PERMIT ISSUING FEE$
Date: TOTALS FEE �3 __.. -•--r=' �
Signature r
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT Z
I hereby affirm that I am exempt from the Contractor's License Law NAME C% ,_f-j-I/0�—11 20�A C ® _ _,...s = -�• .F
for the following reason (Section 7031.5, Business and Professions / '
Code): ADDRESS Z 7 S/-)°�-STS e LA{�
❑ I, as owner of the property, or my employees with wages _
as their sole compensation, will do the work and the CITY AR-(! AP9 1/,006EL.NO. 67Y�77ge
structure is not intended or offered for sale (Section 7044,
Business and Professions Code). OWNER �A
❑ I, as owner of the property, am exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code). -
CONSTRUCTION LENDING AGENCY CITY LA q o,91 7 TEL.NO.
I hereby affirm that there is a construction lending agency for . CONTRACTOR G f+-J
the performance of the work for which this permit Is issued EL��Ad✓/t?�L Ccs i
(Sec.3097, Civ.C.).
ADDRESS `Zg! ff A"
Lender's Name CITY e06 TEL.NO.
15-7y 17754S
Lender's Address STATELIC.
I certify that I have read this application and state that the above LICENSE NO. 3 7 2 7 2 CLASS G Zd
information is correct. I agree to comply with all County ordinances
and State jaw relatin to building construction,and hereby authorize
represe t IIv S of t s County to enter upon the above-mentioned
proper f Iio+L,p`rp�ses• SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATURE OF APPLIC NT OR AGENT DATE