HomeMy Public PortalAbout9578 LOWER AZUSA RD_Mechanical__ ION
WORKER I have
of consent to 200048 DPW 9/89 APPLICATION FOR PERMIT LIME GREEN,
I hefeby affirm that 1 have a certificate of consent to self insure 78A3a4C
or a certificate of Worker s Compensation Insurance or a certified HEATING-VENTILATING-AIR CONDITIONING
copy thereof(Sec 3800 Lab C) 'U
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 (PRINT OR TYPE ONLY) ADDRESS
Date LOCALITY
Applicant NO TYPE OF APPLIANCE OR EOUIPMENT FEE YM
CERTIFICATE OF EXEMPTION FROM WORKERS Cgr
COMPENSATION INSURANCE ABSORPTION UNITBTU
(This section need not be completed If the work Invgived by the MAP BOOK PAGE PARCEL
permit Is for one hundred dollars($100)or lose) AIR HANDLING UNIT CFM DWRI T no PROCESSED BY
I certify that In the performance of the work for which this permit
Is Issued I shall not employ any person In any manner so as to BOILER BTU �D O
become subject to the Workers Compensation Laws o
COMPRESSOR BTU
Date Applicant VENTILATION SYSTEM APPROVALS DATE 04SPECTOR 8 SIGNATURE
NOTICE TO APPLICANT If after making this Certificate of ROUGH
Exemption you should become subject to the Workers Compensation EVAPORATIVE COOLER
provisions of the Labor Code you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked FURNACE FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATIO C T°i
I hereby affirm that I am licensed under provisions of Chapter 8 SUSPENDED UNIT r 25(commencing with Section 7000) of Division 3 of the Business and HEATER WALL 7=7
Professions Code and my license is In full force and effect
�. 2 ITEM-S
License Number Ltc Clara601hme�mi �4 r, d 8 2 17 ® 2=:59
Contractor Date '041 , wy, 11,° IL
❑ I am exempt under Sec Plan check fee d CW q3 °Chi V
Q
B&P C for this reason PERMIT ISSUING FEE$
Date TOTAL FEE OIX_13-12001 ��116192 W
Signature PLAN CHECK APPLICANT Q ro 1947 1 AM 10 7 Z
OWNER BUILDER DECLARATION Ci
I hereby affirm that I am exempt from the Contractor s License Law NAME , v
for the following reason(Section 7031 b Business and Professions t
Code) ADDRESS C C I Y
A
❑� I as owner of the property or my employees with wages ;7 � '3,'c C1jl
as their sole compensation will do the work and the CITY TEL NO
structure is not Intended or offered for sale(Section 7044 e_3
Business and Professions Code) OWNER A� 8
I as owner of the property am exclusively contracting ADLANTA
with licensed contractors to construct the project (Sec ADDRESS 33117 lir°f
tion 7044 Business and Professions Code) pt
CONSTRUCTION LENDING AGENCY CITY TEL NO 2 IT IOt
I hereby affirm that there is a construction lending agency for CONTRACTOR
the performance of the work for which this permit fa issued N111'. }�I��. 440 .00
(Sec 3097 Civ C)
ADDRESS .l�.
Lender s Name CITY TEL NO CHANGE °00
Lender a Address STATE LIC
I certify that I have read this application and state that the above LICENSE NO CLASS
information is correct 1 agree to comply with all County ordmances 0000—OM1 2/26/92
and tolaws relating to b ddmg construction and hereby authorize
re tat1vls of this n to enter upon the above
mentioned 1949 1 AM10:29
p f r inspe u es. SEE REVERSE FOR EXPLANATORY LANGUAGE
RE OFAMV4ffrE DATE