HomeMy Public PortalAbout5609 HELEO AVE_Mechanical__ WORKER' 0-00 4t.
COMPENSATION 76A364
4C 9189 APPLICATION FOR PERMIT IJ E GREEN
I hereby afRhave rm that 1 have a certificate of consent to Solt insure,
or a certificate of Worker's Component. Insur nce or a certified HEATING -VENTILATING,AIR CONDITIONING
copy'/her ($¢c. 3gB0)La
Policy/y'//�b((l /-'7-•/: CM,any COUNTY OF LOS ANGELES DEPT OFPUBLIC WORKS BUILDING AN SAFETY DIV.
�J Certified copy is hereby furnishe .
J. CkM le o is filed with the oun ildin .ins inspection FOR APPLICANT TO FILL IN [NEAREST
DING n ^
S tf PY 9. P RESS
(PRINT OR TYPE ONLY) -
Dote / Applic t ALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WO KE�2S'
COMPENSATION INSURANCE L./ SS ST.
ABSORPTION UNIT,BTU ESSOR
(This Section ne¢d not be eompleletl if the work involv¢d by the BOOK PAGE PARCEL
permit is.for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO. PROCESSES BY
I.certify that in the performance ofthe work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU �. Ol+- _
become subject to the Workers' Compensation Laws. -2 25 CJ
COMPRESSOR,BTU
APPROVALS DATE INSPECTOR'S SIGNATNNE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become Subject to the Workers' Compensation EVAPORATIVE COOLERq
provisions of the Labor Code, you must forthwith comply with such FINAL L
provisions or this permit shall be deemed revoked. FURNACE: AU�s�1 AVITV
�
LICENSED CONTRACTORS DECLARATION FLOORZSR VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER SUSPENDED—UNIT—
(commencing
USPENDED UNIT_(commencing with Section 7000) of Division 3 of the Business and WALL
Professions Code,
/�and
my license i3 in full force and effect.
License Number J �3S� Lic.Class _vp
Contractor / W Date ' 0
❑ I am exempt under Sec. Plan Check fee G r
CC
BAP.C.for this reason PERMIT ISSUING FEE$ O
Date: TOTAL FEE
9 '1 27 �"�! �iei W
Signature OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT j TTS'I` W
_ Z
I hereby affirm that I am exempt from the Contractor's License Law NAME t m � a
for the following reason (Section 7031.5, Business and Professions
Code): ADDRESS NECK
a
EJ1, as owner of the property, or my employees with wages .C1K
as their sole compensation, will do the work and the CITY TEL.NO.
structure is not intended or offered for sale (Section 7044, /
Business and Professions Code). OWNER
EJ // '
^
I, as owner of the property, am exclusively contracting
with licensed contractors 40 construct the project (Sec- ADDRESS *�-,,,,.
tion 7044,Business and Professions Code). -
CONSTRUCTION LENDING AGENCY CITY .-6 -/7/0
I hereby affirm that there is a construction lending agency for CONT CT ,
the performance of the work for which this permit Is issued
(Sec.3097,Civ.C.). "
ADY&SN
Lender's Name
CI TEL.NO. q_
Lender's Address STATE v9�rL'J LIC -
I certify that a read this application and state that the above LICENSE NO. CCS) ��//�� CLASS O
information i crorr t. I agree to comply with all County ordinances
and Stale 1 s reing to building construction,and hereby authorize
represent vee this County to enter upon the above-mentioned
props f s ctio p - es. 7/�' f� l SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATOR OF APPLICANT OR AGENT / 7 DATE Y ,