HomeMy Public PortalAbout5638 GRACEWOOD AVE_Mechanical__ hereby 4fflrmthat Ihavea ccertal}Iccaate4off consent Otoo self Insure, ��� APPLICATION FOR PERMIT LIME GREEN.'or a certtflcnie of Workers Compensation Insurance, or a certMed HEATING-VENTILATING-AIR CONDITIONINGj I
oopy thereof(Sec.3800 Lab.C.) JJ
Pollcy Noy r COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING ANDSAFETY DIV.
ITN Certtfbd copy M hereby furnished.
ElCerfflw oopy Is filed with the couruybuMng tnapeohlon FOR APPLICANT TO FILL IN ADDRESS
(P •� 0
PRINT OR TYPE ONLY)
Data APA�m LOCALITY
tNo. TYPE OF APPtJANCE OR EQUIPMENT FEE .
CERTIFICATE OF E)ONhPTION FROM WORKEW NEAREST
COMPENSATION INSURANCEUNASS86 OR
ASSORPITON Tf Bl"U p/ p'
(ThLs eeot{on need not be oomplated tf Ow wort Involved by file MAP BC(* �O W PA01 O/ PARCi��jle
permtt Is for one hundtrd dollan.(i100J qr teas.) AFl RAm:)LN0 UNIT CFM
I oertlfy that In the performance of the work for whloh this permit
Is Issued, I shell not employ any person In any manner so an to BOQgl BTU
beoomssubject td the Workers'Compensatlon Laws.
COM BTU ,rrriovAts DATe s sar+ATrsS
Data APpkdrt VENTILATION SYSTEM
NOTICE TO APPLICANT: It, after making this Certificate of RDUGH
Exetro.5on,.-you should become subject to the Worker' Compenaedon EVAPORATIVE COOLER
provlalons of the Labor Code„you must forthwhh oomply with suoh FONAI
provisions or this permft shall be deemed revoked. . / FURNACE: FAU VALIDATION
LICENStP CONTRACTORS DECL.ARArTION l FLOOR 13TU
I hereby affirm that I am licensed under provisions of Chapter O 13LwE DED U
ti
(commenng with Sectlon 7000)•of Division 3 of the Business and HETI WAI I
Professions Code,and my noon",is In full foroe and btfeot.
•Lbsnes Nmtw Lk Ctase p
Contractor Dole 114.10 S
❑ I am exerro under Sea Plan Check fee J 3
BABP.C.for tlds reason PERMIT ISSUING FEE i 1 ITEMS O
Date. TOTAL FEF i TOTAL 114 _ 10
CK
CHE114.10 a.
L PLAN CHIC(APPIJCANr
OWN ER-BU I I-DER oECLAAATFON .00 Z
I hereby afflrm that I am exempt.trom ths-Contractore Lloanaa Law NAME
' for the following reason (Seotlon 7031.6, Business and Protessions
Code): . ADDRESS003D-0001 12! 1/91
LON I, u owner o}the property, or my employees with wages n�
ae their sole oompensatlon, will do the work and the WY TEL NO. 35'2'7 1' A�{10:D4
structure Is not Intended or offered Tor sale.(Sectlon 7¢44,
Buslnees and Proteesbns Code). OWNER
❑ I, as owner of the.propeity, am exoluslvely contraoting MALL
with Iloensed oontractore to ponstruot the projeot (Seo- ADDRESS III—b-flap
tion 7044, Bualneea and Profeeelons.Code).
CONSTRUCTION LEND{NG AGENCY, CITY TEN_.NO. _
Ihereby affirm that there Is a oA
onstruotlon lending apenoy for OR
the performanoe of the work for whloh this permit Is Issued
(Seo.3077,Ctv.C.).
ADDRESS -
LarKW4 Name. —
CnY TEL NO.
Lenders Address STATE LJC.
I certfty that I have reAd this applloatlon and state that the above LICENSE NO. CLASS
frlbmisUoR Is correoL 1 agree to comply wffh all County ordinances
brld State jaws DqpwA to butang coromicYion,and hereby aultrortze
r*pr9s0Ma0115z of thla'County to enter upon the above-mentloned
p rty for Inspection p ! SEE REVERSE FOR EXPLANATORY LJUMAOE
BATE
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