HomeMy Public PortalAbout5450 HILTON AVE_Mechanical__ WORKER'Shave a certificate
DECLARATION ?6A3�C PW 9/89 APPLICATION FOR PERMIT ��� ���
I hereby affirm that I have a certificate of consent to self insure,
or a certificate of Worker's Compensation Insurance, or a certified HEATING VENTILATING-AIR CONDITIONING
copy thereof(Sec.3800 Lab.'C.) -
Policy No.3129ILO'Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
Certifietl copy is hereby furnished.
Certified copy is tiled with the county building inspection FOR APPLICANT TO FILL IN BUILDING �� '
tleparQtment. (PRINT OR TYPE ONLY)
ADDRESS
Applicant LOCALITY
// NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM�r� RKERS' NEAREST
COMPENSATION INSURANCE CROSS ST.
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(5700)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY.
I 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 �•Q -
become subject to the Workers'Compensation Laws. fr- t
COMPRESSOR,BTU 4,000 21�
APPROVALS HATE INSPECTOR SIGNATURE ...
Date Applicant VENTILATION SYSTEM A 1
NOTICE TO APPLICANT: after making this Certificate of ROUGH
y
Exemption,you should become
1.5-Z
subject to the Workers'Compensation EVAPORATIVE COOLER `
provisions of the Labor Cade, you must forthwith comply with such FINAL rj�Zai�I tU 4¢
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 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 ;T"P Lic.Class`--A
(
10—`-' QVj
Contractor, `I� 1 40y1 � Date ' I U
❑ I am exempt under Sec. Plan Check fee _ Q
B.&P.C.for this reason - PERMIT ISSUING FEES 0
Date: TOTAL FEE �C' d
Signature O7
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT Z
I hereby affirm that I am exempt from the Contractor's License Law NAME1. -
for the following reason(Section 7031.5, Business and Professions '` '
Code): ADDRESS El y D �O� _ 03I, as owner of the property, or my employees with wages
as their sole compensation, will do the work and the Cl TEL.NO. 'Z�C• -i
structure is not intended or offered for sale (Section 7044, V 95-X75/�G•J 3303 79=f�c
Business and Professions Code). OWNER �G�u T.
❑ I, as owner of the properly, am exclusively contracting MAIL = !TEMS
with licensed contractors to construct the project (Sec- ADDRESS � 79 -05�IffA-j
tion 7044, Business and Professions Code). I _,q
r`5
CONSTRUCTION LENDING AGENCY CITY TEL.NO. CHECK
19.05
1 hereby affirm that there is a construction lending agency for if
the performance of the work for which this permit Is issued CONTRALTO I L�^ �L , MAKE .00
(Sec.3097,Civ. C.). p� -
ADDRESS 1 V '
Lender's Name lY n �ry
CITU ✓1�.,//`'1 TEL.NO. / JUUU-Orl0i ci i //
4=r
Lender's that
Address STATE e /--g LIC. CIU - 0495 l �;h) 9=="
I certify that 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
represe tatives of this County to enter upon the above-mentioned
proper o inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
SIG U E APPL IT 09 AGENT DATE