HomeMy Public PortalAbout6258 MUSCATEL AVE_Mechanical__ 2MO
NdOthat I' COMPENSATION
ate of consent to 76A346DPW9/89 APPLICATION FOR PERMIT LIME GREEN..
r�••" � 76A364
I hereby affiprl that 1 have a certificate of consent to self insure, �7
or a ceftificate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING I I
copy theredl(Se .3800 Lab.C. _/ I u
Policy No.l �v Company � ��[ AYJ(/y COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
❑ Certified copy is hereby furnished. 1;2T
0 Certified copy is filed with the county building Inspection FOR APPLICANT TO FILL IN BUILDING �7Ca
(PRINT OR TYPE ONLY) ADDRESS 2,S—y
Q M I4s
Am�i
(/1 ✓�/I , ,/
Date Applicant LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS
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(11100)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. a
I COMPRESSOR,BTU
APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH _f 9
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL of
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAM ITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU :] [My VALIDATION
1 hereby affirm that I 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 Number S J 93` LID.Class ,DS
�(r ti , t-16-. a S 112
'
Contractor ►y Yfn 41n LI t&Date 01*2 v0JAY3-` q- C
F1 am exempt under Sec. Plan Check fee j i_a Vii` Q
B.&P.C.for this reason PERMIT ISSUING FEE$ L �QTOTAL 122 - C
_-
Date: TOTAL FEE t_(.BECK t���i:! LLL
Signature PLAN CHECK APPLICANT C"HA`NGE a j;0
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law NAME ,
for the following reason (Section 7031.5, Business and Professions Isra tm f__
Code): ADDRESS 0 0 Of/ 91/9-f
1, as owner of the property, or my employees with wages „ / _
as their sole compensation, will do the work and the CITY7m TEL.NO
structure is not intended or offered for sale (Section 7044,
Business and Professions Code). OWNER
❑ I, as owner of the property, am exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRESS (i(
tion 7044,Business and Professions Code). r�
CONSTRUCTION LENDING AGENCY CITY m TEL.NO.
I hereby affirm that there is a construction lending agency for CONTRACTOR II ,
the performance of the work for which this permit Is issued r(n
(Sec.3097,Civ.C.). ALJ
ADDRESS I b/
Lender's Name ��-•
CITY m �� C? TEL.NO. -
Lender's Address STATE LIC. 1�
I certify that I have read this application and state that the above LICENSE NO. ` CLASS ` • 1?v
information is 9prrect. I agree to comply with all County ordinances
!EW
byilding construction,and hereby authorize
unt o enterupon the abovQ-mentionedur ses. { SEE REVERSE FOR EXPLANATORY LANGUAGE
SONATURE- F APPLICAf O GENT DATE