HomeMy Public PortalAbout5130 GLICKMAN AVE_Mechanical__r _
r WORKER'S COMPENSATION DECLARATION 76A364CDPW 9/89 APPLICATION FOR PERMIT LAME GREEN .
I hereby affirm that I have a certificate of consent to self insure,
or a certificate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING
copy there S31800 La C.)
Policy No. / +6-1- Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
❑ Certified copy is hereby furnished. .
Certified opy is filed with the con b din inspection FOR APPLICANT TO FILL'IN BUILDING .
dep (PRINT OR TYPE ONLY) ADDRESS YjZ�°L,
Date Applicant LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORK NEAREST
CROSS ST.
'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)oriless.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
certify.fhat 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 �y r C
become subject to the Workers'_Compensation Laws. I//O
COMPRESSOR,BTUIon �
_ 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 `,�
provisions or this permit shall be deemed revoked. FURNACE:' FAU GRAVITY VALIDATION
LICENSED CONTRACTORS DECLARATION FLOOR BTU
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.
License Number '�f✓ Lia Class��
IL
ACCT.g
Contractor Date
Plan check fee 3 1 50.55 U
❑, .1 am exempt under'Sec. `f' �r cc
B.&P.C.for this reason PERMIT ISSUING FEE 1 ITEMS g®
Date: TOTAL FEE & TE TOTAL 50 5.5 L
Signature CHECK 50.* (o
PLAN CHECK APPLICANT,
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's,License Law NAME CHAN'GE'
for the following reason (Section 7031.5, Business and Professions
Code): ADDRESS'
❑' I, as'owner of the property, or my employees with wages 0000-110131 4 J
as their sole compensation, will do the work and the CITY TEL.NO. [,'+c i qq • i
structure is not intended or offered for sale (Section 7044, 7+ra s CiI� i°�i='
Business and Professions Code). OWNER
El1, as owner of the property, am exclusively contracting MAIL
with licensed contractors to construct the project (Sec-' ADDRESS
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY TE
Ihereby affirm that there is a construction lending agency for CONTRALTO
the performance of the work for which this permit Is issued
(Sec.3097,Civ.C.). �
ADDRESS -
Lender's Name
CITY �`�� TEL.N Yi s.
Lender's Address STATE LIC. '
I certify that I have read,this application and state that the above LICENSE NO:. CLAS
information iscor ct. agree to comply with all County ordinances
and"State laws r -ting o building construction,and hereby authorize
represent five of thi ounty to enter upon the above-m ntioned
property r' spe o urpose SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATURE OF APPLICANT OR AGENT DAT