HomeMy Public PortalAbout9236 PENTLAND ST_Mechanical__ i
W012%FRS COMPENSATION DECLARATION 76A364C
I ti&eby affirm that I have a certificate of consent to self CE 818 (2 80) - APPLICATION FOR PERMIT
insure or ater,rticateofWorkers Compensation insurance,or , HEATING-VENTILATING-AIR CONDITIONING
a terrified sop) thereof(Sec 3800 Lab C) i
Policy No Company
❑ Certified copy is hereby furnished COUNTY OF LOS ANGELES BUILDING AND SAFETY
❑ Certified copy Is filed with the count) budding inspection BUILDING q /
department FOR APPLICANT TO FILL IN ADDRESS 2; (j N1011W) . S7
Date v Applicant (PRINT OR TYPE ONLY)
` LOCALITY �/�/
CLRTIf ICATE OF EXEMPTION FROM WORKERS' NO _ TYPE OF APPLIANCE OR EQUIPMENT FEE Elnn��e
COMPENSATION INSURANCE CROSS ST T d
(This sttiwn need not be completed If the Work mvolved ABSORPTION UNIT BTU - 'F��- vS ��/r�� 0
by the permit is for one hundred dollars ($100) or,less) - Dlsrmcl /' Pnocessep ev f-a L)
I certify that in the perfou mince of the Work for which this AIR HANDLING UNIT CFM-
permit
1J/✓J�( cc
permit issued, 1 shall not employ any person in any manner. ��JJ o y. O
so as to become subject to the Workers Compensation hws BOILER BTU ,
p APPROVALS DATE I*CJ�5SIGNAT, nEDZte _�/C l _ Ue000 0 U O - — a7COMPRESSOR BTU_ _ fn
NOTIC'TO APLIICANT If after making thu CvrUftcata of VENTILATION SYSTEM .f 2
Exemption, you should become subject to the Workers FINAL _
Compensation provisions of the-Labor Code you must forth EVAPORATIVE COOLER VALIDA O
with comply with such provisions or this permit shall be -'
deemed revoked - FURNACE F A U ;i0*NAV ITY '
LICENSED CONTRACTORS DECLARATION FLOOR TU /O o0
1 hereby affirm that 1 am licensed under provisions of Chapter HEATER SUSPENDED UNIT
-9 (commencing with Section 7000) of Division 3 of the Bust WALL
ness and Professions Code, and my license is in full force and
effLCt
License Number-1/4-107,7- Ltc Clars_ % / I t
Contractor_ /`/—tat p-�-- ,I
I am axeexerom the hcensmg requirements as I am e t.
licensed_ architect or a registered professional engineer Plan check fee 25% of above „
acting in my professional capacity, 7051, Bus _
mess and Professions Code) PERMIT ISSUING FEE $
L,c or Reg No Date TOTAL FEE p7�
HOME OWNER BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's NAME S ✓
License Law for the following reason (Section 7031 5 Buse _ o N/ �p/v I t _
ncss and Professions Code) ADDRESS a f '*
qk- G PeNlI�A) S%L'E ACCT
.4v as owner of the property will do the walk and the ) eft
❑ sltactur< is not intended or offered for sale (Section CITY ' �Em�/E Q 7 TEL NOQ/ -2Z 1 (0 ; - .. ,. 3W - - .-'42.75
7044 Business and Professions Code) ' . 1 / G+ o
❑ JWNER - SON✓'4 ,L EO�rCS
1 as owner of the property am exclusively contracting �_
with licensed contractors to construct the project- MAJL �r - - . TOTAL- -- 42 7�
(Section 7044 Business and Professions Code) ADId RESS 7 ATt'l f}S 9 g O t/ -` -
`" CF�CK 42.75
CONSTRUCTION LENDING AGENCY CITY I TEL NO e, _
1 hereby affirm that there is a construction lending agency - .00
for the performance of the work for which this permit m CONTRACTOR
issued (See 3097 Civ C)'
Lenders Name ADDRESS, A 0000-0001 6/19/89
Lender a Address - CITY - - TEL NO " - - 4044 1 G
f9t Ay p:15
1 Witty that I have read this application and state that the STATE LIC -- - -� -
above information u,correct 1 agree to comply with all County 11 LICENSE NO CLASS -
ordmances and State laws regulating Heating Ventilating and _
LAII,ronditioning and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGEty to enter upon the above mentioned property furcNgn f•rrposes
V
enmittee Date - -