HomeMy Public PortalAbout5642 GRACEWOOD AVE_Mechanical__ ION
WO1KEf3'SCOMPEN SATate of consent to 76A346DPW9/89 APPLICATION FOR PERMIT1AME GREEN
76A364C
I hereby affirm that I have a certificate of consent to self insure,
or a certificate of Workers Compensation Insurance, or a certified HEATING -VENTILATING -AIR CONDITIONING
copy thereof(Sec. 3800 Lab. C.) 9
Policy No. Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
❑ Certified copy is hereby furnished.
❑ Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN BUILDING I
PRINT OR TYPE ONLY ADDRESS
department. ( )
Date Applicant LOCALITY -
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' 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($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO, PROCESSED BY
I certify that in the performance of the work for which this permit <, -wti
is issued, I shall not employ an person in an manner so as to
P Y Y P Y BOILER,BTU . ^'� �•e� ,�
become subject to the Workers'Compensation Laws.
i
COMPRESSOR,BTU
APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
(commencing with Section 7000) of Division 3 of the Business and WALL
Professions Code,and my license is in full force and effect.
License Number Lic.Class
CL
d d
Contractor Date 0
❑ Plan check fee } �. `+ V
I am exempt under Sec. LU
B.&P.C.for this reason PERMIT ISSUING FEE$ Y t I Ki
Date: t t f i.," a r LL
TOTAL FEE Signature Q
9 OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT { Q
1 hereby affirm that I am exempt from the Contractor's License Law NAME
for the following reason (Section 7031.5, Business and Professions
ElADDRESS LU
Code): q
( �.t +
I, as owner of the property, or my employees with wages H
as their sole compensation, will do the work and the CITY TEL.NO. � i
structure is not intended or offered for sale (Section 7044,
Business and Professions Code). OWNER
❑ I, as owner of the property, am exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code).
CITY TEL.NO.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for CONTRACTOR ,
the performance of the work for which this permit Is issued
(Sec.3097,Civ.C.).
ADDRESS
Lender's Name
CITY TEL.NO.
Lender's Address STATE LIC.
I certify that I have read this application and state that the above LICENSE NO. CLASS
information is correct. I agree to comply with all County ordinances
and State laws relattPig to building construction,and hereby authorize
representatives of this County to enter upon the above-mentioned
property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
.qPaNATLRE OF APPLICANT OR AGENT DATE