HomeMy Public PortalAbout5654 PAL MAL AVE_Mechanical__ c
WORKER SCOMPENSATION DECl,4fiATION 7633 DPY`'9%89 APPLICATION_ .FOR PERMIT ���E GREEN-
orhereby affirm that I have a certificate of consent to sell insure 78A'i84C [j
or a certificate of,Worker a Compensation Insurance'or a certified _"i' - `y r HEATING -VENTILATING-AIR CONDITIONING
copyt hereof(Sec 3800 Lab C) f 11
r '
,Polity No" Company '' COUNTY OF,LOS ANGELES; DEPT OF PUBLIC WORKS _ BUILDING AND SAFETY DIVA
-fay. , r - , >
.❑., 'Cemfietl copy hereby furnished r , ' • . t S S ' - • r ,
.. El �JCemhed copy is filed wah the iounty building mspecoon FOR APPLICANT TO FILL IN - 9u'LINDSC
t +
department r (PRINT OR TYPE ONLY) - ADDRESS / •� _
• ,r i LOCALITY
ti,Date Applicant t NO TYPE OF APPLIANCE OR EQUIPMENT , FEE '
'+ CERTIFICATE OF EXEMPTION FROM WORKERS -
CROSS ST Zak
COMPENSATION INSURANCE F i _ ABSORPTION UNIT BTU ASSESSOR
(This section nand not be completed If the work Involved,by the MAP BOOK, i PAGE PARCEL '
permit is for one hun'tlratl dollars($100)or leas) ` I AIR HANDLING UNIT CFM owmcr,w vaocessm ev, ' 4,
,I certify that in the performance of the work for which this permit r i + ' ,y ,
is issued�l shall not employ,any person in any manner so as to BOILER BTU + •y
become subject to the Workers Compensation'Lawe • .� i �(/(� ��L�t,dm� '
q _
7 s o f COMPRESSOR BTU m us aTE vasasciwssxvunais » f
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT If after making this Certificate of _ a _ ROUGH •° v'w,-�
.. .Exemption`you should become subject to the Workers Compensation EVAPORATIVE COOLER
provisions of the Labor Code you must forthwith comply with such c I FINAL _ _
provmions or this permit shall be deemed revoked - FURNACE FAU G VfTY r '
• 0„ , LICENSED CONTRACTORS DECLARATION 'v FLOOR BTU VALIDATION _ r
• hereby affirm that I am licensed under provisions of Chapler 9 SUSPENDED - UNR_ -• e
• (commencmg with Section 7000) of Division 3 of the Business and HEATER WALL
Professions Code and my license is in full force end'eflect
License Number Uc Class ,
Cootracto'r Date A - ' A
❑- I f
°'em ezem1Dl under Sec , Plan check fee - O
w, - • -' f i Q
B&P C for this reason _ . - PERMIT ISSUING FEE $ ,1,7 / - H
'
Date U
TOTAL FEE O O i d
` Signature a ..0 �> r jr11.(. .t ,,. `IL
PLAN CHECK APPLICANT .,(=1
OWNER BUILDER DECLARATION L - ! , _717 j, S,G ?
I hereby affirm that am exempt from ihe'Contractor s License Law NAME k , I 1 - 1, -, e
for the following reason (Section 7031 5 Business and Professions - ►iii 1 I C7 i: v v
ADDRESS • .� 1 i r�lfaL - rs3'_ Ci01 .
IfTJN'1 1•as owner of the property-or my smployees with wages r
as their sole compensation .will do the work end the CRY t TEL NO 0 t HE!(>t
structure m riot intended or offered for sale (Section 7044 - HANG d_
Business and'Professions Code) OWNER • ' CNAt E ,�11
❑ I as owner of the property am exclusively contracting MAR ' 1,
with licensed contractors to construct the project (Sec ADDRESS'
• lion 7044'Business and Professions Code) . r , - - T = tI , ill till]—IfQQ j •1,7.Ti'r� .'
CONSTRUCTION LENDING AGENCY CITY` L TEL NO 1,� i
hereby effirm'that thereiis a construction lending agency for ' 1-07 1 • ,01rl:{7
the performance of the work for which this permit 4s issued CONTRACT �� - ,_ _ a ! `_ V.y.V '='q..:-.-..., >
(Sec 3097 Cw C) _ . I+7yp •.i f i
ADDRESS - _• i��
Lender Name
( CITY _ TEL NO .. +.- +-F-•-- �. .._._` _ __. ,.". -
Lenders Address - 1' r
STATE - - LIC � - -t-- .� � ...--�-
I
certify that I have read this application and stele that the above LICENSE NO CLASS -
intormatlon is correct I agree to comply with all County ordinances _ _ , _ _ _ z __ ' �' r _ a mil
' and State la relating to bwlding construction and hereby authorize
rap
resante a oft `County to enter upon,the above mentioned
props
SEE REVERSE FOR EXPLANATORY LANGUAGE
rsl0 oa burr � A �' ., a - .. - ... '_k. _ -. `� 4'• '— _"_�1''_C_ r.,._C�.x, s,