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HomeMy Public PortalAbout10404 MILOANN ST_Mechanical__ ION WOthat I have a certificate of consent to 76A364DPW e/89 APPLICATION FOR PERMIT L0 GREEN: 1 hereby'�ffirm that I have a certificate oT consent to self Insure, or a certiNcatellof Worker's^Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING copy"thereo)(Ac:3800 Lab.C.) 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 SS department. (PRINT OR TYPE ONLY) Date Applicant LOCALITY NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' CR SS COMPENSATION INSURANCE ABSORPTION UNIT,BTU This section need not be completed If the work involved b the ASSESSOR ( P Y MAP BOOK PAGE PARCEL permit Is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO. PROCESSED BY I certify that in the performance of the work for which this permit is issued, I shall"not employ any person in any manner so as to BOILER,BTU become subject to the Workers'Compennssa��tion Laws. i re COMPRESSOR BTU 0 APPROVALS DATE INSPECTOR'S SIGNATURE Date Applicant VENTILATION SYSTEM ' NOTICE TO APPLICANT: If, after making this Certificate of ROUGH Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER provisions of the Labor Code,you must forthwith comply with such FINAL provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY 34 LICENSED CONTRACTORS DECLARATION FLOOR BTU 9 a- 1� VALIDATION I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT (commencing with Section 7000)of Division 3 of the Business and WALL Professions Code,and my license is in full force and effect. License Number �'`���1' Lic.Class � loor poll. a Contractor - v y Date ) C Plan check fee L I am exempt under Sec. 13 B.&P.C.for this reason ©IV. `VV-e.40% 6,st 1 :' PERMIT ISSUING FEE$ C Date: TOTAL FEE Signature 1�•1�� � PLAN CHECK APPLICANT V OWNER-BUILDER DECLARATION G 1 hereby affirm that I am exempt from the Contractor's License Law NAME the following reason(Section 7031.5, Business and Professions { ; Code): ADDRESS 1, as owner of the property, or my employees with wages' :3_;';': as their sole compensation, will do the work and the CITY I`�„ _ TEL.NO. 5-7'7424C.I structure is not intended or offered for sale(Section 7044, C�[h"` =_i_s` Business and Professions Code). OWNER ` I, as owner of the property, am exclusively contracting MAIL with licensed contractors to construct the project (Sec- ADDRESS fV%Z41 tion-7044,Business and Professions Code). CIN TEL.NO. --V CC CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for CONTRACTOR the performance of the work for which this permit Is issued (Sec.3097,Civ.C.). -- ADDRESS Lender's Name CITY Cc c� TEL.NO. -77"1 Zqy - Lender's Address STATE LIC. ,:,: n, �.•+;-, I certify that I 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 relatirig to building construction,and hereby authorize representatives of this County to enter upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE SIGNATURE OF APPLICANT OR AGENT DATE