HomeMy Public PortalAbout5016 GLICKMAN AVE_Mechanical__ ION
DECLARATI
WORKS ) a certificate
of consent to 76A346DPW9/69 A LICATI®N FOR PERMIT LIME GREE
76A364C
I hereby affirm that � a certificate of consent to self insure, �y
or a certificate of Worker's Compensation Insurance, or a certified HEATING -VENTILATING-AIR CONDITIONING ylul�
copy thereof(Sec. 3800 Lab. C.)
Policy No. "� � � company C�'GG' � :Ae L COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
Certified copy is hereby furnished.
Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN BUILDING
ADDRESS
departm nt. (PRINT OR TYPE ONLY) �j
Z �j51 CSM NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY
Date Applicant ( Ci
NEARECERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST. (.tJ c,-/,- 2-C> >�
COMPENSATION INSURANCE ABSORPTION UNIT,BTU
This section need not be completed if the work involved ASSESSOR
( b P Y the MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU L
become subject to the Workers'Compensation Laws. / 99
COMPRESSOR,BTU
APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL Z (�
provisions or this permit shall be deemed revoked. FURNACE: FAUGRAS �� ,L /
LICENSED CONTRACTORS DECLARATION FLOOR BTU 3LS VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
(commencing with Section 7000) of Division 3 of the Business and WALL
Professions Code, and my license is in full force and effect. /
�1 WIC6-7s
637071 62-62
� f�2 J3
License Number Lic.Class �
Contractor_ MC�'�A N/L�4 L_Date I 0
Plan check fee
❑
I am exempt under Sec.
B.&P.C.for this reason PERMIT ISSUING FEE$ 2` _ _•. 0
Date: TOTAL FEE 113
3
Signature - „ J --�-c.--;. �
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT ?_ ,,.-_'2:
I hereby affirm that I am exempt from the Contractor's License Law NAME GM����R /CIA G�
for the following reason (Section 7031.5, Business and Professions -„ - -
Code):
I, as owner of the property, or my employees with wages ADDRESS �� s%�r�l�j�1 C�L/�✓t=ee S' �//` _.•--•, „- _
as their sole compensation, will do the work and the CITY ArXe- jTEL.NO. sly-77
structure is not intended or offered for sale (Section 7044, Y
Business and Professions Code). OWNER
• ❑ > S`�A�r� I nib/_-�'�s�'�e 6)^/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). q
CITY L !�1 p TEL.NO.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for CONTRACTOR y ,
the performance of the work for which this permit Is issued PCG IvJ�GJyfiNlL-A � e-� r
(Sec.3097, Civ. C.). �y/r
ADDRESS L 5 SSI✓17A &4-A P_4
Lender's Name (�
I CITY Ap ���7� �Im06TEL.NO.
Lender's Address STATELIC. / 6
I certify that I have read this application and state that the above LICENSE NO. 63702:2 CLASS Z v
information is correct. I agree to comply with all County ordinances
and State laws relating to building construction,and hereby authorize
representati s f this Co my to enter upon the above-mentioned
property f pection p rposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATURE F APPLICANT O AGENT DATE