HomeMy Public PortalAbout5024 MCCLINTOCK AVE_Mechanical__ .WORKER'S thatIhave a oNSATION DECLARATION
to 76AS64C leg APPLICATION FOR PERMIT LIME GREEN
•I gereby affirm that 1 have a certificate'of consent to self insure,
or a certificate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING
copq thereof(Sec.3800 Lab.C.)
Poli�yN ^� Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
L�i Certified copy is hereby furnished.
❑ Certified copy is filed with the count buildin inspection FOR APPLICANT TO FILL IN BUILDING �'� pv
departm/�j_nt (PRINT OR TYPE ONLY) ADDRESS f✓2Al. 4) �l�y C.-
Date v pplicant / -1 LOCALITY n�
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
e CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST �S'a
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($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU
become subject to the Workers'Compensation Laws. goo
COMPRESSOR,BTU
APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code,you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: U GRAVITY J! VALIDATION
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
(commencing with Section 7000) of Division 3 of,the Business and WALL
Professions Code,and my license is in full force and effect.
License Number LID.Class rl �
Contractor ", d 11,49 Date /2A!263- , C
❑ I am exempt under Sec. Plan Check fee Q
B.&P.C.for this reason PERMIT ISSUING FEE$ C
Date: TOTAL FEE G
Signature t%
OWNER-BUILDER DECLARATION PIAN CHECK APPLICANT 2
I hereby affirm that I am exempt from the Contractor's License Law NAME t pop.for the following,reason(Section 7031.5, Business and Professions
:
Code i^P i
� ❑ ) ADDRESS � � i'!I�•�i n 3a•
1, as owner of the property, or my employees with wages :c
as their sole compensation, will do the work and the CI TEL.NO. _ +-'�03 ==
structure is not intended or offered for sale (Section 7044,
T T E01 S,
Business and Professions Code). OWNER
❑ 1, as owner of the property, am exclusively contracting MAIL r TOTAL 114
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044,Business and Professions Code). �1 (J
� o ' ��'•_�`� ��.�t a�j`�
CITY TEL.NO.WWI
CONSTRUCTION LENDING AGENCY CHANGE
I hereby affirm that there is a construction lending agency for CONT �� r��� /v ,
the performance of the work for which this permit Is issued C—
the
3097,Civ.C.). ��
ADDRESS 01000-13,11-101
�0U i0�I {t r' ,9;
Lender's Name s,;3_ `—�,I� i ''t',?tln tfY: r`
CI TEL.NO. �/ y 3191. 1 AIM 1 l)52
Lender's Address
I certify that I have read this application and state that the above LICENSE NO. �j CLCASS -�
information is correct. I agree to comply with all County ordinances
and State laws relating to building construction,and hereby authorize
represfintatives this ounty enter upon the above-mentioned
( grope y fo in actio purp s s/J � 1 SEE REVERSE FOR EXPLANATORY LANGUAGE
SI
PAMEX OR AGENT ATE