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HomeMy Public PortalAbout5010 GLICKMAN AVE_Mechanical__ ION DECLARATI WORKS 9 a certificate of consent to 76A346DPW9/89 A LICATI®N FOR PERMIT LIME 76A364C I hereby affirm that B 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.) Policy No. 8'i' Nbompany 0 17�/✓ ❑ COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV. Certified copy is hereby furnished. ER Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN BUILDING - department. (PRINT OR TYPE ONLY) ADDRESS 5,010 G Li [--M/a j-i 4Vw Date Applicant C'" S�j 51+,J 7-1 NO. TYPE OF APPLIANCE OR EQUIPMENT FEENEAREST LOCALITY r� G CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST. L04✓G j' A7-CJ 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($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO. PROCESSED BY I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to BOILER,BTU �� become subject to the Workers'Compensation Laws. COMPRESSOR,BTU 19 2�s6 APPROVALS DATE INSPECTOR'S SIGNATURE Date Applicant VENTILATION SYSTEM NOTICE TO APPLICANT: If, after making this Certificate of ROUGH - Exemption,you should become subject to the Workers'Compensation provisions of the Labor Code, you must forthwith comply with such EVAPORATIVE COOLER FINAL Z f provisions or this permit shall be deemed revoked. I FURNACE: FAU_� yIT � LICENSED CONTRACTORS DECLARATION r FLOOR BTU ev _0 2_"31 2-4 VALIDATION I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT (commencing with Section 7000) of Division 3 of the Business and WALL Professions Code, and my license is in full force and effect. f to !r+/� i� �� �c®�`/:rf 39- 30 License Number Lic.Class [?2-� Contractor Ke- '-f E&e- AN i G A&Te _ C� ❑ .[am exempt under Sec. Plan Check fee B.&P.C.for this reason PERMIT ISSUING FEE$ Gif �� _ s I Date: TOTAL FEE LU Signature (o OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT Z I hereby affirm that I am exempt from the Contractor's License Law NAME MGC I 1 for the following reason (Section 7031.5, Business and Professions rJ Fl L ® `-.1- Code): "-Code): ADDRESS El1, as owner of the property, or my employees with wages as their sole compensation, will do the work and the CITY � � 1 Q toe)6TEL.NO. structure is not intended or offered for sale (Section 7044, Business and Professions Code). OWNER 5- A P_ 5 !V TF_(, NA 7/©n/A ❑ I, as owner of the property, am exclusively contracting MAIL with licensed contractors to construct the project (Sec- ADDRESS 4 iq- tion 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY CITY /A O )/'? TEL.NO. I hereby affirm that there is a construction lending agency for CONTRACTOR ,� - the performance of the work for which this permit Is issued K G i 1 [a r F /�<1 s (Sec.3097,Civ.C.). ADDRESS 12-5- r 1 SA.r..l 1 A C`Lf}�'A _r �-f•f �I Lender's Name 5 . CITY � Av��A ►�j P- /f o C-, ,,TEL.NO. -:52 ,[F"""7i 7 1;&0 Lender's Address STATE LIC. I certify that I have read this application and state that the above LICENSE NO. Ca 3 7 a J� CLASS ca- information information is correct. I agree to comply with all County ordinances and State la s relating to building construction,and hereby authorize represe to es of this ounty to enter upon the above-mentioned prop t f r' Sp io SEE REVERSE FOR EXPLANATORY LANGUAGE 4TF' f.i SIGN YURE f1 APPLICA TOR AGENT