HomeMy Public PortalAbout5014 GLICKMAN AVE_Mechanical__ ION
DECLARATI
WORKS ) a certificate
of consent to 76A346DPW9189 A LIGATION FOR PERMIT LIME GREL. -
or76A364CI hereby affirm thal s a certificate of consent to self insure,a certificate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING
copy thereof(Sec.3800 Lab.C.)
olicy No. 'q `�q Company �= f�6 l �Ac:.L r COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
❑ Certified copy is hereby furnished.
EaCertified copy is filed with the count buildingInspection FOR APPLICANT TO FILL IN BUILDING14
depa ment. y (PRINT OR TYPE ONLY) ADDRESS sn--fG l< M/,,j A✓ r- +
Date q 3 Applicant �+ 5?i 5A�f) jyU' LOCALITY T
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS'
CROSS ST.
COMPENSATION INSURANCE (.,�I_J^ A'2_`J S(�
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($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit �Trps
is issued, I shall not employ any person in any manner so as to BOILER,BTU L�
become subject to the Workers' Compensation Laws.
COMPRESSOR,BTU 4®�C' 215
APPROVALS DATE INSPECTOR'S SIGNA RE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH -3o
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL z-If
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU OLS 0061 3 2 4' VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED—UNIT—
(commencing
USPENDED UNIT(commencing with Section 7000) of Division 3 of the Business and WALL
Professions Code, and my license is in full force and effect.
License Number
Lic.Class
Contractor I e%A Bate l ' -
❑ I am exempt under Sec. Plan Check fee T
C3
B.&P.C.for this reason PERMIT ISSUING FEE$ 2q, ��� "'I_?'=''
Date: TOTAL FEE I�lj _ _ i' .:`: W,= ; W
Signature
PLAN CHECK APPLICANT
OWNER-BUILDER DECLARATION Z
I hereby affirm that I am exempt from the Contractor's License Law NAME
for the following reason (Section 7031.5, Business and Professions f, rt
Code): ADDRESS
❑ I, as owner of the property, or my employees with wages Z Sit 1A �L-f��Lr�+ S 1
as their sole compensation, will do the work and the CITY fA_
_ , A p I A 17+.00jTEL.NO. 7 7 p
structure is not intended or offered for sale (Section 7044, v O
Business and Professions Code). OWNER
I, as owner of the property, am exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRESS t(yccF . /- P_ S%r 4 e-) '
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY TEL.NO.
A �� i
I hereby affirm that there is a construction lending agency for CONTRACTOR I
the performance of the work for which this permit Is issued K G /'I 6:0— /%./;a A(,_ (=G
(Sec.3097, Civ.C.).
ADDRESS f L S r . 5,A,J/ A C &A,*A
Lender's Name /�
CITY AP-CA-3l A 1 tpr7 CJL.NO.
Lender's Address STATE LIC.
I certify that I have read this application and state that the above LICENSE NO. CLASS G 2-
information
information is correct. I agree to comply with all County ordinances
and State relating tobuilding construction,and hereby authorize
represe ti s of this ounty to enter upon the above-mentioned
proper r' p our oses. SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATURE OF APPLICA OR AGENT DAT