HomeMy Public PortalAbout5570 GLICKMAN AVE_Mechanical__ �'rVb COMPENSATION DECLARATION CEA 818 (2-8D) APPLICATION FOR YG �T ,
Thereby. a pe
that I have 4 rdfi ar of cdnsent.to self
lnsuro,,,4k d ficate of Worker, Compensation lnsu�rnce,'oi` HEFTING-VENTILATING-AIR CONDITIONING
a AffedQr�f( 38pony00,fib.C.) Li
COUNTY OF•LOS ANGE LES. BUI LOING-AND SAFETY
'CertlQdd Copy is hereby furnished.' .
Certlfled copy Is filed with the countp building inspection
APPLICANT TO FILL IN
BUILDtN° �( G A✓L
Dat d0°t Applltant "� 1 �l� FOR APP(PRINT OR TYPE ONLY)
ep AbDREg3 55'
J`cam
LOCALITY
NO.- TYPE OFAPPLIAN(;EOREQUIPMENT FEECL'RTIFICATE OF EXEMPTION FROM WORKER-S' (�
COMPENSATION INSURANCENEAREST
(This-sectioti need not be'cornpleted U the vmrk involved ABSOFiP ON NIT,8tU CROSB ST. L •
tiY the'.permit it,{ac onb hundred doll= ($100) or I&la.j DISTRITr ["OCMED Y Q
t Certify that,jn tie performance 'of tha•work for which this AI HANDL NQ•UNIT C-F Tom– t/ tU�
permit ts.Ufuad, I ,hall not employ any person in any manner TV7y �1
?so as to becomd,ubjaCt to the Workels' Compematlon Lawn. BOILER BTU
APPROV,9LS, QATB 1 •Da1BNA E
Dote
Applicant COMPRE OR BTU
ROUQH
NOTICE TO APPLICANT: if,-after making this Certiftcaio of VENTILATION SYSTEM FINAL
Exemption, you should become•,subject to'•the Workers'
Compensation provisions of the Ldbor Code, you must forth- -
wit-h Comply, with such provislons or this permlt'1baU be. EVAPORATIVE COOLER , 'VALIDATION_
-deemed revoked. . . ` ' y
FURNg�4CE: PAU GRAVrTY
'LICENSED CONT"CTOR5 DECLARATI0 4 FLOOFj; BTU
r hereby affirm thet I am licensed under provisions of Chapter HEATER: SUSPENDED NI'C
9•{tornmenctng with Section 7000) o,f Division 3 of the Bull- WALL
noes and Profesaioru G9de a❑d my ticb❑se Is In full force,and
L1ten,a NutlSberLto. Clans
Contractor Date �Z r
Q - a
I ■m'eicempt from th (icensins requirements as em a
licensed archjtect or a registered professional enbineer Pr h check fee 269 Of a"e.
acting In my professiontil, aapsclo (Section 7051, Bus-
PERMIT 4od Profbsalona Code).; PCRMIT ISSUlNf3 FEE +'.. .
. Lic.or Ras.No. Data
TOT,4L FEE
HOME OWN IsR-BUIL.DER'DECLARATJO1N PLAN CHECK APPLICANT, :• ' r
•.1 hnr ,,.. c:
aby aQlrm that 1 sm exempt hom-'the Contractbrs NAM-E , p
License Law for the followtng reason (Sbctlon 7031.5, Busi-
, ngasand Professions Code): APDRES3 F. 1'': FRr1.1-■ �
O 1, u owner'of the property, will do the wort- add the ` , ` :<+ :
structure I, not intended or offered for sale' (S4cHon• CITY TEL. NO.. ip
9044, Business and Professions Code), - �~`
OWNE ^
I• as owner gf.the property, em'excluatvely contricting _ _., M
�wtth .licensed contractors to• construct 'the pro*—t MAIL 1-:+.,� - - -ToT 35 75•
ti (Seaton 7044,Business and Pro(eeuiotla Code). ADDRESS �r . ..
- CONSTRUCTION LEND.INC3 AGENCY 'C.ITY TEL.'NO. � ■f
I hereby affirm,that there '1$ a cowtruction lending agencyy � r
for the performance of the wgrk 'for which this pet'm1t.l,: CONTRA TOR
Issued ((Seo. 3097,Ci .C.). s`
` Landorfs Name ADDRE§5L
v QOOD-M i 8/_
• I,endor',Addresa • t , _. .
. - CITY ��� TE L.�10. � � : - _ ,. ,fit �)
.I Certify thot I• have read this application end rtata that the gTAT LIC. ^. A {11N.
%bbyo In(grmatton Is correct. f■p'ee to comply with all Cbonty S CLASS ��
ordinances and State laws regulating Hosting, Ventilating and '
kir.Conditioning, anhereby authorize ropresenM tativof this SEE REYF-RSE FOR EXPJ„ANATA
ORY LNGUAGE
yy
Counto enter -up
r -up the above- entiooed property for
'tnspbction'pu otos