HomeMy Public PortalAbout5332 NOEL DR_Mechanical__ WORKER I haveCOMPENSATION
ate of consent to DPW 9/89 APPLICATION FOR PERMIT UME GREEN"
I hereby affirm that I have a certificate of consent to self Insure
or a certificate of Worker a Compensation Insurance or a certified HEATING VENTILATING AIR CONDITIONING
copy thereof(Sec 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
department (PRINT OR TYPE ONLY) ADDRESS
Date Applicant NO TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS NEAREST
CROSS ST
COMPENSATION INSURANCE
ABSORPTION UNIT BTU ASSESSOR
(This section need not be completed if the work Involved by the MAP BOOK PAG PARCEL
permit is for one hundred dollars($700)or less) AIR HANDLING UNIT CFM DISTRICT NO ESBED 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 to BOILER BTU
becomeA
ct to the Workers Compensation Lawn
COMPRESSOR BTU
APPROVALS DATE INBPECTORa SIGNATURE
Da APPlica VENTILATION SYSTEM
N TI P L ANT If after making this Certifica of ROUGH
Exam tion you should become subject to the Workers Compe tion EVAPORATIVE COOLER
provisions of the Labor Code you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked FURNACE FAU VITY
LICENSED CONTRACTORS DECLARATION FLOOR B 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 Lic Class LAA"f
a
Contract Date V
E] I am mpt under Sec Plan Check fee RUT s
Q
B&P C for this reason PERMIT ISSUING FEEO
3,-,03 12b 7n v
Date TOTAL FEE GEC)
1 ITEMS
Signature PLAN CHECK APPLICANT !n
OWNER BUILDER DECLARA N TI ITAL 126 0 70 Z
I hereby affirm that I am exempt from the Contractor a ense Law NAMEVAI , t�G�K 1i ��
for the following reason(Section 7031 5 Business and Professions rr c
Code) ADDRESS L HAMGE oil
E] I as owner of the property or my employees with wages
as their sole compensation will do the work and the CITY �- ELNW2Ar-27-4.
structure is not Intended or offered for sale(Section 7044
Bu0000-0001 7/12/99
Business and Professions Code) OWNS
❑ 1 as owner of the property am exclusively contracting MAIL00 1226 1 AM11
with licensed contractors to construct the project (Sec ADDRESS
tion 7044 Business and Professions Code)
CITY TEL NO
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
1
Lender a Name
CITY TEL N
Lender s Address STATE C
I certify that I have read this application and state that the above CENSE NO CLASS �f •
Information is correct I agree to comply with all County ordinances
and State laws relating to building ruction and hereby0puthonze
representatives of this County t ter upon the abov, entioned
props or I spection purpo � SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATUR OF APPLICANT OR ENT DATE