HomeMy Public PortalAbout10766 GRAND AVE_Mechanical__ T)ON
WORKER'S have
aceSAcate of consent
DPW 9/99 APPLICATION FOR PERMIT LIME GREEN
78Ar'ia4C
I hereby aTflrm that I have a certificate of consent to self Insure,
or It oerthlcate of Worker's Compenastlon Insursnoe, or a osrttfled HEATING -VENTILATING-AIR CONDITIONING
copy thereof(Sec.3800 Lab.C.)
No, Comp-q COUNTY OF LOS ANGFl FS DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
Cer[tM1ad copy Is herebyturnlshed.
IXN
[� Certtflad copy Is Il with the county bued%V I FOR APPLICANT TO FILL IN BUADDRE 8
(PRINT OR TYPE ONLY)
D G 2 �S'�'/ CIM L"' �/r1 i7� y
NO. TYPE OF APPLIANCE OR EQUIPMENT FEECER TFICATE OF EXE3APTFON WOR
NEAREST
COMPENSATION INSURANCE Aasok rK N lfNrr,BTU axm ST.
section need not be oompNted K the work Involved by the MAP B30R
(Cho
MAP BOOK � PAGE 7 PAFIC,EL
permit V for ona hundred dollar($1100)or lase.) AIR HAND3LING UNIT CFM Drrrrscr No, PPOCESSED BY
I certify that In the pe-rformanoe of the work for which this permit
Is Iss4ed, I shall not employ ally person In anymanner aq as to TM
hecor.he eUbJect to the Workers'Compensation Lowe. / J �� Q�
62
COMPRESSOR BTU S
,M1FKNA-e DATe srePscrpPrA 803MATure
Dke ApPGoafrt VENIILATYON SYSTEM
NOTICE TO APPLICANT: If, atter making this Certlfloato of ROUGH
Exemption,you should become subject to the Workers' Compensation EVAPORATIVE COOLED
provtslons of the Labor Code, you must fotthwtth comply with such FTIAL —
provlalone or this permit shall be deemed revoked. FURNACE= FAU—()RAvrrY
LICENSM CONtRACTORS DECLARATION FLOOR BTU VALIDATION
I hereby afTlrm that 1 am licensed under proVlelons Cf Chapter 9' HEATERSUSPENDED UNIT
(commencing with Ssotton 7000) of plvlslon 3 of the Buelrleaa and / WALL /
professions Cods,and my license Is In full force end effeo(.
Lloene,Number T
contractor
ctz OAtz
El am exempt under Seo Plan Check foe I=
B.BP.C.for thIs reason PERMIT ISSUING FEE; O'er
TOTAL FEE O fl W
CL
PLAN CHECK APM-CANT Z
VILDER
I hereby afflrrh that I am exempt from the Contractors Uoense Law NAME
for the following reason (Sectlon 703.1.15, Buslness and Professions
God❑s). Al ll R r! T ACCT.T
1, as owner of the property,or my employees wtth wages
as their sole compensation, wlll do th$ work and theCITY L£ TEL NO. �] � f}1.{�I�
structure Is not Intended or offered for sale (Seotlon 7044,
8uslnaes end Proteeslo"Code). OWNER r ' 1 ITEM
LJ 1,D
❑ 1, as owner of the property, pm exclusively contracting MAIL ` TOTAL 61 - 00
with licensed contractors to construct the project (Sec- ADDRESS / �� L.4- 111'�+ L
tipn 7044, Buaineee dad Professlons Cods). CfTY Ta CFECY, �1.W
CONSTRUIfJ(1 AGENCY �N� 4e { (� .4�
I hereby affirm that there Is a construction lending egerioy for CONTRACTOR r o '
the performance of the work for which this permit In Issued
(Sec.3097,Ctv.C.).
Legere Name Ansa �1 6/26/91
CITY rEt_No. r'712 1 AM 7:T,
I�riders AddressATE Lic.
1 oertffy that I he"read this applloatlon and awe that the above �i No. MASS
htormatlon Is correct. I aQTw to comply with aJl County ocdlnarKm .
and State Tawe relating to buMnj oDnatruction,and hereby autho tze
repreeerttaifves of this County t er upon the above-mentioned
p for Inspeotlon P Ir SU REVE}tEtE FOR EXPLANATORY L ANOUAOE