HomeMy Public PortalAbout5635 HALLOWELL AVE_Mechanical__ 20-0046
WORKER'S COMPENSATION DECLARATION 76A364CPW9/69 �����((a/p���®II CI ®It ll I�L�II`llllllll�� MME
\`7"IREEK,I hereby,affirm that I have a certificate of consent to self insure, Ai sv� A `,.I
or a certificate of Wo'rker's Compensation Insurance, or a certified HEATING-VENTILATING'-AIR CONDITIONING
copy thereof(Sec:3800 Lab. C.) "
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
department. ( 6
PRINT OR TYPE-ONLY) - � � l�Bwe—
' • � _' .
Dale Applicant LOCALITY.'NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
- - NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' CROSSST. �1e de iVQ
COMPENSATION.INSURANCE ABSORPTION UNIT,BTUASSESSOR D �Q
(This section need.not be completed'if the work involved by the MAP BOOK O�C) PAGEQ�� PARCEL`�f
permit is for`oae hundred dollars($100)or less.) AIR HANDLING UNIT;CFM
DISTRICT NO. PROCESSED BY ,
Ircerufy that in the performance of the work for which this permit., ;4
is'issued;'l shall'not employ'any person in any manner so.as to BOILER,BTU
•become'Subject to the Workers' Compensation Laws.
COMPRESSOR,BTU
Date Applicant APPROVALS DATE• INSPECTOR'S SIGNATURE
PP VENTILATION SYSTEM
NOTICE TO APPLICANT: ff, after making this Certificate of ROUGH, 30
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith:comply with such FINAL S
provisions or.this permit shall be deemed revoked. FURNACE: FAU GRAVITY Y
LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATION '
hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED • UNIT
.(commencing with Section 7000) of Division 3 of-the Business and HEATER; WALL
Professions Code,and my license is in full force and effect.
License Number. Lic.Class
CLContractor Date " __ _O,
FJPlan check fee - jEr _
Lam,exempt.under Sec .
-t
B:&P.C.for this reason I PERMIT ISSUING FEE$ / J ``-` O
Date: € •i �t�
TOTAL FEE- V
W
_!; F
Signature OWNER-BUILD PLAN CHECK APPLICANT fA
ER'DECLARATION" ' ty t !{1 I3�G f,,Z
I hereby.affirm that I am'exempt from the Contractor's License Law NAME. D n for the following.reason (Section 7031.5, Business and•Professions -
Code): ADDRESS It i E S i,i�.i
❑ I, as owner of the property, or my employees with wages
as their sole compensation, will do the work and the CITY TEL.NO.
structure Js not intended or offered for sale (Section 7044,
oBusiness and Professions Code). OWNER
a C- Sze It-C/12
l,,as owner_of the property, am•exclusively-contracting MAIL f
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044,.Business and Professions Code). _7�2'
CONSTRUCTION LENDING AGENCY CITY 1 t TEL.NO.
Ihereby 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 relating to building construction,and hereby authorize
representatives of this County to enter upon the above-mentioned
proper for inspe "n pur osSEE REVERSE FOR EXPLANATORY LANGUAGE--
IGNATURE AP ANT OR AGENT DATE- '
76 A+,64,-; CF B,B - 9-71
APPLICATION FOR PERMIT
HEATING - VENTILATING - AIR CONDITIONING
COUNTY OF LOS ANGELES BUILDING
DEPARTMENT OF COUNTY ENGINEER ADDRESS
BUILDING AND SAFETY DIVISION LOCALITY
NEAREST
CROSS ST. e
FOR APPLICANT TO FILL IN OWNER
(PRINT OR TYPE ONLY) MAIL -
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE ADDRESS
CITYtEL. NO.
ABSORPTION UNIT, BTU
CONTRACTOR '
AIR HANDLING UNIT, CFM
ADDRESS AA
BOILER, BTU
CITY TEL. NO.
COMPRESSOR, BTU (Jv STATE LIC.
LICENSE NO. CLASS
VENTILATION SYSTEM DISTRICT NO, GROUP ZONE BY
EVAPORATIVE COOLER ; ®g (:2,CESSED
�-
a
FURNACE: FAU RAVITY
FLOOR BTU /ham INSPECTION RECORD
HEATER: SUSPENDED UNIT_ O
WALL U
W
N
' Z
Plan check fee 25% of above. See reverse.
PERI lIT ISSUING FEE 8 3 00
TOTAL EEE
PLAN CHECK APPLICANT
NAME
�A DDRESS
CITY TEL.NO.
I TEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATI.ON
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL ORDINANCES AND LAWS REGULATING HEATING, VENTI- APPROVALS AT NSP R'S SIG ATURE -
LATING, AIR CONDITIONING. '
ROUGH
I HEREBY CE FY THAT I AM NOT ACTING-INVIOLATION
OF CHAPTER 9, DIV ION 3, OF THE BUSINESS A ROF SSIONAL FINALIt
CODE OF THE STATE NIA. L'
SIGNATURE PERMIT VALIDATION CK. M.O. CASH
OF PERMITTEE
PLAN CHECK VALIDATION CK. M.O. CASH
A�_ G 7 F?3 APR 24 4 1 D 1 5.50"
SEE BACK OF APPLICATION FOR COMPLETE FEE SCHEDULE