The URL can be used to link to this page

Home My Public Portal About5612 GLICKMAN AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION APPLICATION .FOR PERMIT 4-l`(lereby affirm that I have a certlflcate of consent to self Insure, or a certificate of Workers' Compensatlon Iruurance, HEATING - VENTILATING - AIR CONDITIONING or a crl fle_cl'�'thereof (Sec. 3800, b. .) 7&A364C CE-818(REV. 10/81) Policy No. Company c�- d Certified copy Is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY ❑ Certlfied copy Is flfed with the county building Inspec- FOR APPLICANT TO FILL IN Bum tion department. PRINT OR TYPE ONLY) cam—Ca—Al- f L0�41 ( . G ` Date Appl ILOCALITY NO. TYPE OF APPLIANCE OR EQUIPMENT FEE NEAREST CERTIFICATE Cif EXEMPTION FROM RKERS' COMPENSATION INSURANCE CROSS ST' L, (This secHon need not be compl"If the work Imrohred by ABSORPTION UNIT, BTU Dl"k7 rvo. PROCOUD BY the parmlt Is for one hundred dollars (;100)or less.) AIR HMIDILING UNIT,CEM v I certify that In the performance of the work for wblch this L permit Is Issued,i shall not employ any erson In any manner so as to bec a aubleci to the Work p mpensation Laws. BOILER, BTU APPRov,ws DATE slow Date 1 pllcont COMPRESSOR, BCU ROUGH ' NOTICE APPLICANT: If, after making thl Certlfloote of VENTILATION SYSTEM F1N�1 b Exempt on, you should become subject to the Workers Compensation provisions of the Labof Code, you must forth- EVAPORATIVE COOLER VALIDATI N with comply with.such provlslons or This permit shall be deemed revoked. FURNACE: FAU GRAVrrY LICENSED CONTRACTORS DECLARATION FLOOR BTU I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT '(commencing with SectloR 7000) of Division 3 of the Business WA1 d and Profesalow Code,and m II rse Is In,full force and effect. - O i ' License Num Ic. Class , � Contractor 4 c' to O ❑ I am exempt under Sec. Plan check fee N B.BP.C. for this reason _ PERMIT ISSUING FEE $ Date: Signature TOTAL FEE - OWNER-BUILDER DECLARATION PLAN,CHECK APPLICANT 1 hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and NAME � T.i Professions Code): 2 �+� E] 1, as owner of the property, cr my employees with ADDRESS7� 3307 307 ?151.`0 wages as their sole Compensation,will do the work and CITY TEL NC b 1 ITEM the structure Is not Intended or offered for sale(Sectlon 7OA4, Business and Ptofessions Code). OWNS - TOT 2Q - 50 ❑ 1, as owner of the property, am exclusively contracting MAIL CASH 50 . with ILcensed contractors to construct the protect (Sec- ADDRESS tion 7044, Business cind Professlons Code) CUM� M CONSTRUCTION LENDING AGENCY CITY TR_ NO. . I hereby affirm that there Is a constructloh lending agency for ^�,r �sy the performance of the work for which this permit Is Issued CONTRACTOR �M�/ �/` , 0000-0 71 1/12/89 (Sec 3097, CIv. C.). ADDR S 093 1 N 12'.O5 Lender's Name CITY TEL NO. 7 Lender:Address srATE uc. I certify that I have read this application and state that the UCENSBNO. CLASS - - above Informatlon 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 u thebove-mend ned property forIon urposes. SEE REVERSE FOR EXPLANATORY LANGUAGE L,,<— Slgm turn Applicant or Agent Date - - "f° 8CO'` ''°"DECLARATION °"8pPW°'°° APPLICATION FOR PERMIT LIME GREEN . I hereby atfirm'that I haa certMcate of consent to self Insure, 78A3a4C w or a oertMcate of.Worker's Compenaatlon Insurance, or a oertMed HEATING-VE)MLATING-AIR CONDMONING copy therrof(Sec.3800 Lab.C.) u No. Comp-YCOUNTYY OF LOS ANQE11 E3 DEPT OF PUBLIC WORKS -BUILDING AND SAFFCY DIV_ Certtw copy Ii hereby tunilshed. ❑ Certified copy Is filed with the oounty building"peau- TOR APPLICANT TO FILL IN SSS 1 tC_ M •� dw-Dront (PRINT OR TYPE ONLY) LOCALITY NO. TYPE OF APPLIANCE OR ECXJPMEKt. FEE CBMFIC,ATE OF DCOIPTION FROM WOR) ' L COMIOfJ - PENSATINSURANCE AasoRP,rotr UtJ7 BTU ASSESSOR (rhis seatJon nod not,be completed H the irork Involved by the MAP BOOK PAGE PAACt1 permit is for one hundred dotlsrs,J$100}or Mae.) AIRI-IIJIDUNG UNrr CFM cc I oertlfy that In the performance of the work for which this permit � �� Is Issued, is not employ any pdreon.'{n any manner so as to BTU. become subject to the Workers'Compensation LR^wen, COMPRESSOR BTO 42o t.e04 O� .�aovrce DATE s+e�rorrs wewnnre VENI'1LATION SYSTEM NO,T[ E TO APPLICANT::' If, .after me ng this Certlfloate of ROUGH Exemption,you ehoukt beoome subject to the Workers' Compensation EVAPORATIVE COOLER - provisions of the labor Code, you must forthwith oomply with such FNAL provlsbns.or th1e permh shall be deemed revoked. FUFKA&= FAU XORA LIC:1 B CONTRACTORS DECLARATION FLOOR BTU VAW6ATION I hereby affirm,that l am licensed under provlslons of Chapter 0 HEATr=R: SUSPENDED UNIT (oommencing with that, 7000) of DtvWon 3 of the Buslnaaa and WALL- Professions Code, Is In full force and effect. . uo G uoenee Num ber�f Lk:.da7s Plan check fee ❑ I am exempt under Soo , Q B.SP.C.for thfa reason PERMIT ISSUING FEE>F o� 0 Dets: TOTAL FEE 00 d PLAN CHECK APPLICANT C0 EF,8Uly6 DECLARATION Z I hereby affitrn that Iem ex pt from the Contrgator's Lldense Law , for the following reason ( en 7031.6, Businessand Profeaalorll Code): t. �--`� AUT Ar E .. 1, as owner of the property, or my employee►with wages + .00-y as thele sole compensation, will do the Work and t �^�y}he , CITY TEL NO. ; �7 53. structure 16 not Intended or offered for salb (8edtlon 7044, Businesa and Professions Code).' OWNER �' 1 ITS I, as owner of the property, em exclusively oontraoting MAIL h TOTAL c IPID with licensed contractors to-construct the project (Seo- ADDRESS 4 �1 FF{{�� x +11 don 7044, Business and Profgealona Code). TEL NO. '•+ cc:` ~ CONSTRUCT"LEWINQ AGENCY I 74 herebyY affirm that there Is a construction lending agency for the periormanCe of the work for whloh this permit Is Issued CONTRACT IN 330088 (8eo. 7,Civ.C.). ADDRESS Lendere.Name - ODOCi-raGCl1.' 7/t.5/T't CITYTEL No. ii ��t_ Lenders�ddreee STATE Nc. lam -.1 I Y 1 11:41 I certNy that L have read this application and state that the above LICENSE NO. CtABS Information le correct. I agree to comply with al11 County ordinances. and Stale laws reladng to,building oonatructfon,and hereby authoitre representatfvbe of this County to-enter upon the above-men'doned property for In n p SEE REVERSE FOR EXPLANATORY LAWMJAOE Ttss OR DATE `