HomeMy Public PortalAbout9082, 9082 1/2 LAS TUNAS DR_Mechanical__ OMPENSATION DECLARATION 200046 DPW 9/89 APPLICATION FOR PERMIT LAME GREEN
76A364C
I hal Irm at 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)
pPolicy No Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
1[ Certified copy Is hereby furnished -t
j ❑ Certified copy Is filed with the county budding Inspection FOR APPLICANT TO FILL IN BUILDING
department (PRINT OR TYPE ONLY) ADDRESSTunasy
Date Applicant LOCALITY
NO TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST of
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($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO PROCESSED BY
I certify that in the performance of the work for which this permit
Is Issued, I shall not employ any person in any manner so as to I BOILER,BTU - -
become subject to the Workers'Compensation Laws
COMPRESSOR,BTU
' APPROVALS DATE INSPECTOR'S SIGNATURE '
DateAp Icant VENTILATION SYSTEM
NOTICE TO APPLICAN f, after making this Certificate of ROUGH
Exemption,youshout e s ct to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Lab d 0 ust forthwith comply with such FINAL �—
provisions or this per t he I b d emed revoked FURNACE FAU GRAVITY
LICENS O T ORS DECLARATION FLOOR BTU VALIDATION
I hereby affirm that I e sed under provisions of Chapter 9 HEATER SUSPENDED UNIT
(commencing with action 000) of Division 3 of the Business and WALL
Professions Code, nd my cense Is In full force and effect
License Number #33228 Llc Class G-4
Contra Data U � Q
❑ I am exempt under sec Plan check fee �a 0 `g
B&P C for this reason' PERMIT ISSUING FEE$ 0 7 O
Date TOTAL FEE Q W
Signature CL
PLAN CHECK APPLICANTr Z
OWNER-BUILDER DE RA I 1.
I hereby affirm that I am exempt from the Con ctor's License Law NAME ' 'r•" s
for the folloXPd
ason (Section 7031 5, B mess and Professions '`I °Ir
a 2_
Code) ADDRESS p,0.BOX 59148 '��'� `''°''I€
❑ I, ar of the proper, y em yeas with wages T Y t+
as ole compens 0n, 11 o the work and the CITY TEL NO T IEIs�
strunot Intend off d for sale (Section 7044, NORWALK CA. 310-802-524 _ SIT. �EBusnd Profe I ns ode OWNERl i riLI, ar Of e p e y, exclusively contracting Cor oration `_H .�t +�MAIL .3°crwitse contra to to onstruct the project (Sec- ADDRESS ,_�(rt��Etionusiness a d Professions Code)
NSTRUCTION LENDING AGENCY CITY TEL.NOeI hereby aat there is a construction lending agency for rj� Ir', t� I I 6::**?Q 194
the performance of the work for which this permit is Issued CONTRACTOR AS ABOVE ► r__V—t1��1
($ec 3097,Civ C)
ADDRESS =k�nL Hl f L a=t1
Lender's Name
CITY TEL NO i
Lender's Address
I certify that I have read this application and state that the above LICENSE NO LIC
r_Aq
Information Is correct I agree to comply with all County ordinances
and Stat ws relating to building construction,and hereby authorize
repro entad sof this County to enter upon the above-mentioned
property for 1 spection poses SEE REVERSE FOR EXPLANATORY LANGUAGE
�S_�,
PLICANT OR AGENT DATE ,