HomeMy Public PortalAbout5319 GLICKMAN AVE_Mechanical__ �,V(N` KERS'COMPENSATION DECLARATION CEA36 8(2-80) APPLICATION ®I� PERMIT
hereby uf;irm that I have a certificate of consent to self
insbre, ora e;tificate of Workers' Compensation Insurance,or HEATING-VENTILATING-All Ft CONDITIONING
a certified copy thereof(Sec. 3800, Lab. C.)
Policy No. Company
1 ❑ Certified copy is bereby furnished. �q` COUNTY OF LOS ANGELES BUILDING ARID SAFETY
Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN BUILDING
de art ent. I ADDRESS �Q / CLYV
Date �� A licant __, \^'_\__ �_ (PRINT OR TYPE ONLY)
��� PP U E LOCALITY �e C� �� l
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FE NEAREST }
COMPENSATION INSURANCE
CROSS ST. a-
(This section need not-be completed if the work involved ABSORPTION UNIT,BTU p
by the permit is for one hundred dollars ($100) or less.) DISTRICT O. PROCESSED By
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM
permit is issued, I shall not employ any person in any manner O
so as to become subject to the Workers' Compensation Laws. BOILER,-BTU
(� (`�{� APPROVALS DATE IN F TOR'S SIGN ATI E W
DateC Applicant__ _ _ 1 COMPRESSOR, BTU �v��� `� 0 ROUGH U)
NOTICE TO APPLICANT: if, after making this Certificate of - Z
VE<`ITILATiON SYSTEM _ m
.Exemption, you should become subject to the .Workers' FINAL _ —
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION
with comply with such provisions or this permit shall be
deemed revoked.
j FURNACE: FAU .GRAVITY
LICENSED CONTRACTORS DECLARATION ( FLOOR: BTU A)
I hereby affirm that I am licensed under provisions of Chapter HEATER: SUSPENDED UNIT
9 (commencing with Section 7000) of Division 3 of the Busi- WALL
ness and Professions Code, and my license is in full force and
effect. OLk-f(le--tS
License Number 5�2a® Lic.Claws, Vi - q�� /
ContractorAtiT�D Date /��� .y
❑ I am exempt from the licensing requirements as I am a
licensed',architect 'or a registered professional engineer Plan check fee 25%of above.
acting in my professional capacity (Section 7051, Bus-
ness and Professions Code). - PERMIT ISSUING FEE
Lic.or Reg.No. Date TOTAL FEE
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
_.
I hereby affirm that I am exempt "from- the Contractor's NAME
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): ADDRESS r1tr
. 1
Elp property, AC
I, as.owner of the ro y,'v✓ill do the work and the. CITY TEL. NO. �+�+'
structure is not intended or offered for sale (Section ,9A7 �
7044, Business and Professions Code).
❑ I, as owner of the property, am exclusively contracting OWNER �qt-rt�,c'.��- ������ i.. L
with licensed contractors to construct the project MAIL'
(Section 7044, Business and Professions Code). ADDRESS JI ` l` ''�Q �" ��
CONSTRUCTION LENDING AGENCY CITY T@h1 [e2c� TEL. NO. yYK111.
�
I hereby affirm that there is a construction lending agency A
for the performance of the work for which this permit is CONTRACTOR � -
issued(Sec. 3097,Civ.C.).
Lender's Name ADD,RESS i '
Lender's Address NO / t, t 7"ffig
CITY n�'sJl/ b�c�] �� 1
I certify that I have read this application and state that the STAT ^ 7� ROB-
LIC. r
above informution is correct. I agree to comply with all County LICENSE NO. � CLASS
ordinances and State taws regulating Hearing, Ventilating and -
Air Conditioning, and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
County to enter upon the above-mentioned property for
;, p,-ctjon purpoosse�s. ��ture of Permittee Date