HomeMy Public PortalAbout5438 PAL MAL AVE_Mechanical__ PWORKERS COMPENSATION DECLARATION APPLICATION FOR PERMIT
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. I offirMi that I have a certificate of consent to self
insure, or a witificco of#Kkere-Eempematrn Inturonce,
or a Cori7 � HEATING - VENTILATING - AIR CONDITIONING
fied pry thereof(Sec 3800, Lab C )
acy No4P YS Company �/+ DPW 9/58
Certified copy is hereby furnished COUNTY OF LOS ANGELES BUILDING AND SAFETY
❑ Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING
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tion department (PRINT OR TYPE ONLY) ADDRESS
Date IOLZZ2 Applicant LOCALITY
NO TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' t4"EST
COMPENSATION INSURANCE CROSS ST
(This section need not be w If the work Involved by ABSORPTION UNIT BTU DISTRICT NO PROC S11D BY
the psrmh Is far one hundred dollars ({100)or less)
I certify that In the performance of the work for which this AIR NANDUNG UNIT CFM—
permit
FM permit Is issued, I shall not employ any person in any manner U
so as to become subject to the Workers'Compensation Laws BOILER BTU APPROVALS DATE INSPECTOR S SIGNATURE
Dots Applicant COMPRESSOR BTU I D G a — ROUGH
NOTICE TO APPLICANT If, after making this Certificate of VENTILATION SYSTEM FINAL -��-
Exemption, you should become subject to the Workers
Compensation provisions of the Labor Code you must forth- EVAPORATIVE COOLER VALIDATION
with comp]y with such provisions or this permit shall be deem-
edrevaked FURNACE FAU_GEAWTY
LICENSED CONTRACTORS DECLARATION FLOOR BTU –{
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 WAU
and Profewiom Code,and my Incense is In full force and effect
License cenNumber LIc Class ►a-'L O
� n V
Contractor '21� Date / y K
❑ I am exempt under Sec
Plan check fee
B BP C for this reason h
Date PERMIT ISSUING FEES — _
Signature APPLICANTTOTAL FEE
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License ,
Law for the following reason (Section 7031 S, Business and NAME
Professions Code) p
El 1, in owner of the property, or my employees with ADDRESS
wages a their sole compensation,will do the work and AC(T.A
the structure is not Intended or offered for sole(Section CITY TEL NO
70", Business and Profestiom Code) 707 ?7. 0G
I, a owner of the property, am exclusively contracting 01m 2
with licensed contractors to construct tha project (Sec- SIL 3eVC 1 ITEMS
tion 70", Business and Profeftoru Code)
CONSTRUCTION LENDING AGENCY -I-
GENCY11 TI)TAL 37 - 00
1 hereby affirm that there is a construction lending agency for CITY C i '7 U �o��j— , (HE(K 37.1313
the performance of the work for which this permit is Issued CONTRACTOR
(Sec 3097, C ��
_ CHANGE .(0
Civ C ) 7
Landes Name CESS �D 4?
Lenders Address CITY lr-ei y TEL NO ��/ 0000-0001 111/11/91)
I certify that I have read this application and state that the �� NO 1J'7 CLASS a 3260 1 AM10:07
above Information Is correct I agree to comply with all County
ordinances and State jaws relating to building construction,
and hereby authorize representatives of this County to enter
upon the abovpppvvmTT++entionrd property for Inspection purpose
GI /` /0 // O SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicortt or Agent Dot ms