HomeMy Public PortalAbout5928 MUSCATEL AVE_Mechanical__ ION
WORKER'S I have
a certificate
of consent to 20-0046 DPW APPLICATION FOR PERMIT LI E GREEN
I�reby 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
copy ther�ti (Se .3800 a��) y
Polic No an t . COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
❑ Certified copy is hereby furnished.
Ce 'fled copy is filed with the cc my 1 �Ig ins ction FOR APPLICANT TO FILL IN BUILDING J SG!
Is nt. (PRINT OR TYPE ONLY) ADDRESS 0
Date ) A licant t LOCALITY -�
pp NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
NEAREST C&A
CERTIFICATE OF EXEMPIF
TION FROM WORK R CROSS ST.
COMPENSATION INSURANCE ABSORPTION UNIT,BTU
SOR
(This section need not be completed if the work involved by the MA BOK PAGE LPARCEL
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
certify that in the performance of the work for which this permit
s issued, I shall not employ any person in any manner so as to BOILER,BTU 1nf
ecome subject to the Workers'Compensation Laws. ' �. V 1 /J�y
COMPRESSOR,BTU
1)66 WAPPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
Vrovislons of the Labor Code,you must forthwith comply with such FINAL
(provisions or this permit shall be deemed revoked. FURNACE: LMUCt� RAVnY A VALIDATION
f LICENSED CONTRACTORS DECLARATION FLOOR
hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSP NDED UNIT
commencing with Section 7000)of Division 3 of the Business and WALL
rofesslons Code,and my license Is in full force and effect.
!cense Number Lic.Glasse
ontractor Date t✓ ® Q
I am exempt under Sec. Plan check fee - L
'` M
BAP.C.for this reason PERMIT ISSUING FEE$ 1 H
Date: TOTAL FEE '
LL
Signature a
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT U
hereby affirm that I am exempt from the Contractor's License Law NAME
or the following reason(Section 7031.5, Business and Professions
ode): ADDRESS
I, as owner of the property, or my employees with wages
as their sole compensation, will do the work and the CITY TEL.NO.
structure is not intended or offered for sale(Section 7044, 00
Business and Professions Code). OWNER
1, as owner of the property, am exclusively contracting MAIL �^`� �n
with licensed contractors to construct the project (Sec- ADDRESS ' '+i�+C
tion 7044,Business and Professions Code). — J�-7
CONSTRUCTION LENDING AGENCY CITY TEL.
hereby affirm that there is a construction lending agency for CONTRALTO I
he performance of the work for which this permit is issued
Sec.3097,Civ.C.).
ADDRESS
ender's Name
CITY TEL.N
ender's Address I
certify that I h e read this application and state that the above LICETNSE NO. 1X LIC.
nformation!s rre I agree to comply with all County ordinances
nd StatAOFAPPLIC.ANT
re to building construction,and hereby authorize
repres tat' f t County to enter upon the above-mentioned
props s e n r oses. SEE REVERSE FOR EXPLANATORY LANGUAGE
(SIGNATURE OR AGE VATE