HomeMy Public PortalAbout5532 PARMERTON AVE_Mechanical_1/2/1990_compressor,inlet,outlet,central heater WORKERS COMPENSATION DECLARATION APPLICATION -FOR PERMIT
' hereby affirm 41hat I have a certificate of consent to self - J�
msyre, or a certificate of Vorkers,Csampensatlominsuran2$ - HEATING • VENTILATING - AIR CONDITIONING '
or a certified copy thereof (Sec 381X} Lab C 1 ,T6A3k4C . s. >
10-0046 DPw 9%BB� ' �< - - '
Policy No Company -
Certified copy is hereby furnished COUNTY OF LOS ANGELES BUILDING AND SAFETY
_•Mfr'❑.
f Certified copy is filed with county building inspec- BUILDING
❑ FOR APPLICANT TO FILL IN Z pq(1f�lo�}�yl AJ'Q
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M ` . I , , »� � , (PRINT OR TYPE ONLY)- p� �y
Date SSL Appl166nt ,. 115-ti
r , LOCALITY 15-sPIe— Cl ly-Y
NO TYPE OF APPLIANCE OR EQUIPMENT FEE
� CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST `
' COMPENSATION INSURANCE CROSS ST - I%N�
4• f + , . t
(This section nand not be completed If the work involved! by UNIT BTU by - DISTRICT NO P y s
the permit Is for one hundred dollars ($100) or lass ) '
I certify that yin the performance of the work for which this AIR HANDLING UNIT CFM ��
permit is issued I shall not employ any parson in any manner , t
' •�so as to become subject to the Workers COmp9nsah On Laws BOILER BTU' •' 'APPROVALS` DATE- INSPECTOR IGNATURE
j` r e COMPRESSOR BTU ROUGH .�
Dote Applicant
t NOTICE TOS APPLICANT If after mokuig this Certificate of VENTILATION SYSTEM' - FINAL
7 f
,t Exemption you should become subject to the Workers /
't • Compensation proviLons•of the Labor Code, you must forth- EVAPORATIVE COOLER _ _ • VALI ATION
with comp)y with such provisions or this permit shall be deem
I` ed revoked l ' , _ r FURNACE FAU_GRAVITY r
LICENSED CONTRACTORS DECLARATION FLOOR - - BTU
r
Hereby affirm that I am licensed under jxovivoro of Chapter 9 HEATER SUSPENDED UNIT— ,
(commencing with Section 7000)of Drvmion 3 of the Business "' '"WALL .Y t
and Professions Code and my license is in full force and effect 21-2-
License
License NumberUc Class ` O w
" r �e L > to o atU U
Contractor - Date• . _ Oe
D•+ ❑ 1 am exempt under Sec 1• "� O
' ' "I • 1. Plan check feerd
' B&P C for this reason ' s e , ' ' a
s'r . -. t e PERMIT ISSUING FEE $ Z
" TOTAL FEE DO
Signature
OWNER BUILDER DECLARATION PLAN CHECK APPLICANT - _ �• ,
I hereby affirm that I am exempt from the Contractor s License ,
Low for the following reason (Section 7031 5, Business and NAME
Professions Code)
El I, as owner of the property, or my employees with ADDRESS- + `
wages as their sole compensation will do the work and p ^
the structure is not intended or offered for sale(Section ' CITY........ ' ._ TEL NO .r
7044 Business and Professions Code) * • r + < ,
] OWNER_ ,
I, as owner of the property,t, am exclusively contracting _ . '
t
with licensed contractors to construct the project (Sec MAIL � j3�] S3.[6
hon 7044^Business and Professions Code) ADDRESS .-.'
CONSTRUCTION LENDING'AGENCY'r ::- -
QTV TEL NO I ITEM
I hereby affirm that there 1s a construction lending agency for- = '^ TOTAL 83 . 00
the performance of the work for which this permit 1s issued CONTRACTOR
(Sec 3097 Civ C ) - ADDRESS t ►• -CHECK 23.U1)
Lender s Nanta _ `y7 tc ,.'r ft..LHMGE •.L41
s
CITY TEL NO
Lender s Address
I certify that I have read this application and state that the LICENSE NO Cu55 - � ' QQQQ-OOOIVI ?/90
above information 1s correct I agree to comply with all County '� - -� L 9
•ordinances and State laws relating to building construction �f •� - 7917 1 " 'l
and hereby authorize representatives of this County to enter v
upon the;, ;e-mention d properly for inspection purposes - - _ + --^ - - - - - - '
SEE REVERSE FOR EXPLANATORY LANGUAGE ,
roture of Applicant or gent Date , r �-