HomeMy Public PortalAbout6211 MUSCATEL AVE_Mechanical__ ION
WORKER'S I have
a certificate
of consent to 20-0046 DPW 9/89 APPLICATION FOR PERMIT LIME GREEN
78A364C
I hereby affirm that I have a certificate of consent to self insure,
or a•certificgUiof Worker's Compensation Insurance, or a certified HEATING-'VENTILATING-AIR CONDITIONING
copy.thereof(Sec.3800 Lab.C.)
P lioy No k Company_STATS FUND 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 6 2 G L ��
department. (PRINT OR TYPE ONLY) ADDRESS
Date Applicants�Z��,
1 LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE �
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST LON 1
COMPENSATION INSURANCE CROSS ST. /V
(This section need not be completed if the work Involved by the ABSORPTION UNIT,BTU RASSESSOR
MAP BOOK PAGE PARCEL
permit Is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO. PR CESS/ED BY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU
become subject to the Workers'Compensation Law.
` y COMPRESSOR,BTU 3�2�0 I3T1I 3
APPROVALS DATE INSPECTOR'S SI NATURE
Dates Applicant VENTILATION SYSTEM
NOTICE T APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. Z FURNACE: FAU_7_1,-r_OGRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU V LIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED-UNIT-
(commencing
USPENDED UNIT(commencing with Section 7000)of Division 3 of the Business and HEATER: WALL
Professions Code,and my license is in full force and effect. Ea
License Number 69'7 I 3 0 Lic.Class C—z V
® Ag
Contractor� 10 Data s CCT e C
❑ I am exempt under Sec. 1 Plan check fee 3303 179.90 �
1ITEMS C
B.&P.C.for this reason PERMIT ISSUING FEE$ TOTAL 7L o '0 C
Date: TOTAL FEE a CHECK 179.90 n
Signature
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT CHANGE .00 G
1 hereby affirm that I am exempt from the Contractor's License Law NAME
for the following reason(Section 7031.5, Business and Professions 000.
Code): ADDRESS 0000-0001 5/28/96
❑ I, as owner of the property, or my employees with wages 3 666 1 PM
as their sole compensation, will do the work and the CITY TEL.NO. 2 °4:53'`-�
structure is not intended or offered for sale (Section 7044,
Business and Professions Code). OWNER pJC
YJ
I, as owner of the property, am exclusively contracting MAIL Rp L
Id
with licensed contractors to construct the project (Sec- ADDRESS 1
tion 7044,Business and Professions Code). �
CONSTRUCTION LENDING AGENCY CITY TEL.NO, j Z`7'6
1 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 O
,*121,4650 TEL.NO.7 ��
Lender's Address STATE //
I certify that I have read this application and state that the above LICENSE NO. (Oq�/ O LIC.
information is correct. I agree to comply with all County ordinances
and State laws relating 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