HomeMy Public PortalAbout5012 GLICKMAN AVE_Mechanical__ ION
WORKE - a certificate
of consent to 76A346DPW9/39 A LIGATION FOR PERMIT 1.19111E GREL. _
76A364C
I` I hereby affirm that a 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.)
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Policy No. Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
❑ Certified copy is hereby furnished.
BUILDING
J9 Certified copy is filed with the county building inspection FOR APPLICANT EToOLFILL IN ADDRESS j tJ Z- s s L(�K dL'J A rvr (/.,
departm nt.
Date Z 5 Applicant 12$2 15f O, LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST. 1,ot-ope A2_
COMPENSATION INSURANCE ABSORPTION UNIT,BTU
This section need not be completed if the work involved b ASSESSOR
( P Y the MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU
become subject to the Workers'Compensation Laws. -1�
COMPRESSOR,BTU G �
APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM i
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH _ _
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL .
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY yy
LICENSED CONTRACTORS DECLARATION FLOOR BTU14:!?e at 7i7 VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT
(commencing with Section 7000) of Division 3 of the Business and HEATER: WALL
Professions Code, and my license is in full force and effect. /) � I aZ
License Number 63 ? 0 7176
Class 6 2-C;' / - EL
Contractor Elie- 612z41
❑ I am exempt under Sec. Plan Check fee -
B.&P.C.for this reason PERMIT ISSUING FEE$ 2LB '' - ---
Date: TOTAL FEE �l J? LU
C?
Signature .,e`s^'``•',;';„ ��I'i �
PLAN CHECK APPLICANT U)
OWNER-BUILDER DECLARATION Z.
I hereby affirm that I am exempt from the Contractor's License Law NAME �1 /rl�CI�(� j�� �✓
for the following reason (Section 7031.5, Business and Professions M
Cod
❑e). I, as owner of the property, Or my employees with wages ADDRESS �q,-
as their sole compensation, will do the work and the CITYTEL.NO. ���
structure is not intended or offered for sale (Section 7044,
Business and Professions Code). OWNER �- p_ /�/ � ✓ w/zk.- I a","J
❑ I; as owner of the property, am exclusively contracting MAIL f
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY Z, A. '700-7 TEL.NO.
I
hereby affirm that there is a construction lending agency for CONTRACTOR r ,
the performance of the work for which this permit Is issued ��
(Sec.3097, Civ. C.).
ADDRESS aZ
Lender's Name 7 f
CITY A X cf A P I A- TEL.NO.
Lender's Address STATE j LIC.
I certify that I have read this application and state that the above LICENSE NO. 7 Cs / CLASS C
information is correct. I agree to comply with all County ordinances
and State ws/�elating to bVilding construction,and hereby authorize
rpeprpesey a�sAfia�o(i ty to en pon-the above-mentioned
ro er s cti n p' os s. SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATURE OF APPLICANT OR AGENT DAT