HomeMy Public PortalAbout5021 GLICKMAN AVE_Mechanical__ WORKER'S COMPENSATION DECLARATION 20-0046 DPW 9/89
hereby rp afar 76A364C APPLICATION FOR PERMIT LIME GREEN
that I have a certificate of consent to self insure, I �j
or a certificate of Worker's Compensation Insurance, or a certified HEATING,VENTILATI-NO.-AIR CONDITIONING yl�jll
copy thereof(Sec.3800 Lab.C.) J
Policy No. Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
Certified copy is hereby furnished.
❑ Certi ied c py is filed with the county building inspection FOR APPLICANT TO FILL IN
BUILDING
(PRINT OR TYPE ONLY) ADDRESS
1-711M
rtme
Date 1 Applicant LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTI FROM WORKERS' NEAREST
CROSS ST.
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 G
become subject to the Workers'Compensation Laws. C W e `
j COMPRESSOR,BTU SQ Ori
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
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provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY
l LICENSED CONTRACTORS DECLARATION FLOOR BTU �� / VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 HEATERSUSPENDED UNIT
:
(commencing with Section 7000) of Division 3 of the Business and WALL
Professions Code,and my license is in full force and effect.
7 Dom'
License Numb 5Lia Class 01111". IL
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Contractor � Date r 0
❑ I am exempt under Sec. Plan Check fee _ cc
B.&P.C.for this reason PERMIT ISSUING FEE !�Q z�'-'= a'S
Date: I CL
TOTAL FEE O z) __!_I i[,I LU
SignatureLAN CHECK APPLICANT CD
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OWNER-BUILDER DECLARATION --- —�Cr
I hereby affirm that I am exempt from the Contractor's License Law NAME (7L
for the following reason (Section 7031.5, Business and Professions
Code):
ADDRESS
ElI, as owner of the property, or my employees with wages w �Q _Yt ii':%__ �-1-'
as their sole compensation, will do the work and the CITY � '�Q f TEL.
structure is not intended or offered for sale (Section 7044,
Business and Professions Code). OWNER
❑ 1, as owner of the property, am exclusively contracting MAIL 's
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code).
CITY TEL.NO.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for -CONTRACTOR ,
the performance of the work for which this permit Is issued �( }tii�J A-y�'7_,
(Sec.3097,Civ. C.). d
ADDRESS Q _ 8 ���t� A-,,kz;-
Lender's Name
CITY a (4 f ,� TEL.NO. ,(�.QL6-3_%i
Lender's Address STATE V LIC. 1 r
I certify that I have read this application and state that the above LICENSE NO. �f ?�f, CLASS C—X
information is correct. I agree to comply with all County ordinances
and State laws relating to building construction,and hereby authorize
representatives of this County to enter upon the above-mentioned
pr ty for in erre rposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
SI M1fAT OF PPLICANT OR AGENT DATE