HomeMy Public PortalAbout5646 HALLOWELL AVE_Mechanical__ ION
WOthat I have
a certificate
of consent to 20-0046 DPW
PW 9/69 QPPL�ICAMN FOR PERnn�T I hereby affirm that I have a certificate of consent to self Insure, udu INEE,
or a certificate of worker's-Compensation Insurance,:or a ceruf!edHEATING-VENTIL/4TING•AIR CONDITIONING
. copy thereof(Sec.3800 Lab.C.)
Policy No. Company CE -�V COUNTY OF LOS ANGELES• DEPT OF PUBLIC WORKS BUILDING AND"SAFETY DIV.
Certified copy ishereby furnished.
Certified copy is filed with the count buildi in a ion FOR APPLICANT TO FILL IN BUILDING
depa lent./ y g p (PRINT OR TYPE ONLY) ADDRESS J e7 e,
Date �7 L APPlicant LOCALITY �f 7�L� L'%T r,.e, /��®"',
�NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST.
COMPENSATION INSURANCE ABSORPTION UNIT,BTU
(This section need not be completed if the work involved by the ASSESSOR
MAP BOOK ." .. PAGE .• PARCEL,
permit is for one hundred.dollars'(il00)or less.) AIR HANDLING UNIT,CFM DISTRICT No. PRocesseD BY
1 certify that in the performance of the work-for which this permit
is issued;I shall not employ'any,person in any manner so as to BOILER,BTU /�°�
or
become subject to the Workers',Compensation Laws. �7 - 5. 06
Z COMPRESSOR,BTU
_ APPROVALS DATE INSPECT 'SSIGNATURE.." '
Date - `'Applicant ` VENTILATION SYSTEM 7�
NOTICE TO APPLICANT: If, after.making this Certificate of ROUGH ?—! —
Ezemption,.you should become subject-tq the Workers' Compensation EVAPORATIVE^COOL ER
provlsigns,of the Labor.Code;you must forthwith comply with such FINAL Z_I
provisions or this permit shall-be deemed revoked.. :•FURNACE. FAU GRAVITY '
LICENSED CONTRACTORS-DECLARATION FLOOR BTU CP 60 :VALIDATION:
,:'a •`
I'hereby affirm'that I am licensed un der 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.
In
,'rr/ 2 3 v
License Number T-'7 7s-3 Lic.Class
.• • • :;ate„
�rrLA5_7a .�M O
Contractor Date
❑ '
I'am exempt under Sec: Plan ChQCk f8l'
B.&P.C.for thi PERMIT,,ISSUING FEE$ `7S non O
TOTAL FEE a
Signature _
'OWNER-BUIL ECLARATION is "• PLAN CHECK APPLICANT ' - - z
hereby affirm-that 1 am exempt,from the Contractor's License Law NAME
for the following reason (Section 7031.5,Business and Professions D ,
Code): ADDRES
❑. I, as owner of the property, or my-employees with wages.
as their sole compensation', will do the work and the CITY TEL.NO. — i_?
structure isnot intended or offered for sale (Section 7044,
F_JBusiness and,Professions Code). OWNER wf �" !!�
I, as owner.of the property,'am-exclusively contracting- MAIL
with licensed contractors to construct the project (Sec- ADDRESS Q ,
tion 7044, Business and Professions Code). -
CONSTRUCTION LENDING AGENCY CITY s C T
I hereby affirm that there is a construction lending agency for, 'd`c rNAN ''"`
the performance of the work for which this permit.is issued CONTRACTOR 4W7I.p/�gy
(Sec.3097, Civ.C.).
ADDRESS
Lender's Name
CITY TEL.NO.
Lender's Address STATE LICA
-
Certify that I have read this application,and'state that the above LICENSE NO. �/?j ,r CLASS-
information is correct..I agree to'comply with all County ordinances
and State laws relating.to building construction,and hereby authorize
r' `tatives of is County.to enter upon the above mentioned
property r insp tion purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATURE OF APP '-- ATE - -