HomeMy Public PortalAbout5219 PAL MAL AVE_Mechanical__ WORKER'S COMPENSATION of consent to 76A34sDPWel89 APPLICATION FOR PERMIT LIME GREEN
76A364C
I hereby affirm that I have a certificate of consent to self Insure,
or a certificate'of Worker's 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. p
❑ Certified copy is filed with the county building Inspection FOR APPLICANT TO FILL IN BUILDING tt��DDRESS 6O C PAL- MA�
department. (PRINT OR TYPE ONLY)
Date ApplicantLOCALITY �r ,
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
Is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU
become subject to the Workers'Compensati L ws.
�� N COMPRESSOR,BTU c®
Date Applicant ° VENTILATION SYSTEM APPROVALS DATE INSPECTOR'S SIGNATURE
NOTICE TO APPLICANT: If, after ma ng this&1irtificate of ROUGH /Y
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY—
LICENSED
LICENSED CONTRACTORS DECLARATION FLOOR BTU 6 VALIDATION
1 hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT
(commencing with Section 7000)of Division 3 of the Business and HEATER: WALL
Professions Code,and my license is in full force and effect. 10 I 0(AT Q ere 6
License Number �` Y Lic.Class °�_-)w9 Ca
�1 �
® rii•�1 o s _
ContractorC •a r-``LIE 1 I m ATS-D
p p ate ' —�� -'�I t� ±i �'=r C
❑ I am exempt under Sec. Plan Check fee i ITE{3 C
BAP.C.for this reason PERMIT ISSUING FEE$ !�C t E rTAL 97 - 9 -0 C_
Date: TOTAL FEE CHECK �'f°�' U
Signature 1� n
t•�I�
PLAN CHECK APPLICANT ',7E °LIQ U
OWNER-BUILDER DECLARATION G
1 hereby affirm that I am exempt from the Contractor's License Law NAME
for the following reason(Section 7031.5, Business and Professionst i 2' 9",.
Code): ADDRESS O�J�D-CIU01f �f�:
❑ I, as owner of the property, or my employees with wages jy26 1 Ail 7n47
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 M JZt%rLS RfJ(2,o BARD-CrO
❑ I, as owner of the property, am exclusively contracting MAIL /�
with licensed contractors to construct the project (Sec- ADDRESS S 2- 19 PAL- Y fn/�■A L— pr 88
tion 7044,Business and Professions Code). CIN"Taw le, L bT'r T 57.5'f3 /
CONSTRUCTION LENDING AGENCY n
I hereby affirm that there is a construction lending agency for CONTRACTOR - AlPL
the performance of the work for which this permit Is Issued C��-1F®tWI(� GLIMA � ��®,
(Sec.3097,Civ.C.). ADDRESS FA j PG PZW /We
Lender's Name CITY A C1 1004 TECIf t. -qq7,ff;�v
Lender's Address t.,(
I certify that I have read this application and state that the above LICENSE NO. ! 7�3SZ LIC.
information is correct. I agree to comply with all County ordinances
and State laws relating to building construction,and hereby authorize
representatives gif this County to enter upon the above-mentioned
prop t for in actio s. SEE REVERSE FOR EXPLANATORY LANGUAGE
` , -7-tea -53
SIGNATU OF APPLICANT OR AGENT DATE