HomeMy Public PortalAbout9903 NADINE ST_Mechanical__ L _Q VJn%at 'SG$MPENSATIOe of consent to 200046 DPW 9/89 APPLICATION FOR PERMIT `IME GREEN,
78A384C
• L ftereby..@Nirm t I'have's cerllficate of consent to self Insure,
"or 9 Urtificate of WorkerAs-dompensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING
copy thereof(Sec.3800 Lab.C.) L�
Policy No. Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS , BUILDING AND SAFETY DIV.
Certified copy is hereby fumished.
❑ Certified copy is filed with the county building Inspection FOR APPLICANT TO FILL IN BUILDINGS 3 /17-
department. (PRINT OR TYPE ONLY) T /�
Date Applicant LOCALITY 1 Pxh Ie- l..l'
- N0. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST.
ABSORPTION UNIT.BTU ASSESSOR pp p
(This section need not be completed If the work Involved by the MAP BOOK �Sp 8 PAGE 018 PARCEL 00/
permit Is for one hundred dollars($700)or less.) AIR HANDLING UNIT,CFM DtsTRtCT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER BTU •A �j
become subject to the Workers'Compensation Laws. !�Q
COMPRESSOR,BTU
APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,'you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code,-you must forthwith Comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY '
LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT
(commencing with Section 7000)of Division 3 of the Business and HEATER:
WALL
Professions Code,and my license is in full force and effect.
License Number Lic.Class , - }
Contractor Date
❑ Plan check fee _
I am exempt under Sec. 0
B.&P.C.for this reason PERMIT ISSUING FEE$ 11--
Date:
Date: TOTAL FEE d
Signature IL
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT Z
I hereby affirm that I am exempt from the Contractor's License Law NAME ,
for
dddthe following reason (Section 7031.5, Business and Professions
r )" ADDRESS 1'-f.l iL Lu = 6
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,
Business and Professions Code). OWNER
F1 I,'as owner of the property, am exclusively contracting MAIL ` v�
with licensed contractors to construct the project (Sec- ADDRESS O rt^ �. " l="''
tion 7044, Business and Professions Code). t'I'h-I" E
CONSTRUCTION LENDING AGENCY CITY CI TEL.NO.
I hereby affirm that there Is a construction lending agency for CONTRACTOR
the performance of the work for which this permit la issued
(Sec.3097,Civ.C.).
ADDRESS
Lender's Name
CITY TEL.NO. ,
Lender's Address
C.
I certify that I have read this application and state that the above LICENSE NO. CLLASS
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
p pyrty for inspection purposes, SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATURE OF APPLICOR AGENT DATE