HomeMy Public PortalAbout5308 MCCLINTOCK AVE_Mechanical__ ,r
►WORKER'S COMPENSATION DECLARATION 76AWaDPW9/e9
76A364C APPLICATION FOR PERMIT LIME GREEN
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� l� CompantJ�rl�j 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 BUILDINGDDRESS
eparlme�nft. ) (PRINT OR TYPE ONLY) A
Date ^� Applica NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY
rw7 // „
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST. C
CROSS ST.
COMPENSATION INSURANCE ABSORPTION UNIT,BTU
OR
(This section need not be'completed if the work Involved by the MAP BOOK PAGE PARCEL
permit Is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
I certify that in the-performance of the work for which this permit
is Issued, I shall-not employ any person in any manner so as to BOILER BTU I J
become subject to the Workers'Compensation Laws. /0LQ U � dC���tP-cam
l COMPRESSOR BTU
' APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code,you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVI.
LICENSED CONTRACTORS DECLARATION FLOOR BTU G� ALIDA ION
1,hereby affirm that's am licensed under provisions of Chapter 9 SUSPENDED UNIT
(commencing with Section 7000)of Division 3 of the Business and HEATER: WALL
Professions"Code,and my license is in full force and effect.
License Numbs Lic.Class �/ -0412
poll. CL
}
Contract v i ate C
El am exempt under Sec. Plan check fee
' D
B.&P.C.for this reason PERMIT ISSUING FEE$� 3 J D C
Date: I TOTAL FEE pp LL
Signature Q
PLAN CHECK APPLICANT U.
OWNER-BUILDER DECLARATION C
1 hereby affirm that I am exempt from the Contractor's License Law NAME ,
for the following reason (Section 7031.5, Business and Professions
Code): ADDRESS A{CT.TT
❑` 1, as owner of the property, or my employees with wages _
as their sole compensation, will do the work and the ' CITY TEL.NO.. .7307 a #j
structure is not Intended or offered for sale(Section 7044, +
Business and Professions Code). OWNER 1 ITEMS
❑ I, as owner of the property, am exclusively contracting MAIL TOTAL 55 a 00
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044,Business and Professions Code). CITY TEL.NO. CHECK 55.130
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for CONTRALTO %l �S ' � � I�I
the performance of the work for..which this permit is Issued 1G
(Sec.3097,Civ.C.). Zid y`t t .� f{
y/ ADDRESS � / IJ�.fI�i(.i"RJIJII f 6/21/91
Lender's Name q
r TEL. to:i3 1 AM 9 o 47
Lender's Addressa�r Lry
I certify that I have read this application ands that the above LICENSE NO. ? LIC.
p�
information is correct. I agree to comply with all County ordinances
and State laws relating to building construction,and hereby authorize
representatives of thJs County to enter upon the above-mentioned
property for inspe Ion p off �j' SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATURE OF AFFPLICANT OR AGENT DAT c�j