HomeMy Public PortalAbout5319 PERSIMMON AVE_Mechanical__!!�� r
Rs°RLS" COMPENSATION DECLARATION ;
, A t ffi m that I have a certificate of consent to self
insure, or a certificate of Workers' Compensation Insurance,
or a fertified dopy thereof (Sec. 3800, Lab. C.)
Policy No. ' ' Company
Certified copy is hereby furnished.
❑ 'Certified copy is filed with the county building inspec-
tion department.
Date Applicant
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the work involved by
the permit is for one hundred dollars ($100) or less.) '
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 become bject to the War s' Co ens t* n Laws.
Date pplica
NOTICE TO PLICANT: If, a making this Cer' ate of
Exemption, you should become subject to the -Workers'
Compensation provisions of the Labor Code, you must forth-
with comply with such provisions or this permit shall be
deemed revoked.
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9
'(commencing with Section 7000) of Division 3.of the Business
and Professions Cocd/e, and my license is in full force and effect.
License Nummbeerr, ,,/ 7 5 Y&;2! pL.ic. Class c_ 7,0
Contractor`��y!Y��
❑ I am exempt under Sec.
B.&P.C. for this reason
Date:
Signature
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and
Professions Code):
❑ I, as owner of the property, or my employees with
wages as their sole'compensation, will do the work and
the structure is not intended or offered for sale (Section
7044, Business and Professions Code).
❑ I, as owner of the property, am exclusively contracting
with licensed contractors to construct the prolect (Sec-
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for i
the performance of the work for which this permit is issued
(Sec. 3097, Civ. C.).
Lender's Name
Lender's Address
I certify that I have read this application and state that the
above information is correct. I agree to comply with all County
ordinances and State laws relating to building construction,
and hereby authorize representatives oft County to enter,
upo Aof
v mentioned prop ty for ' pectin rposes.
=gn tulicant or Agent Date '
APPLICATION
76A364C HEATING - VENTILATING
CE - 818 (REV. 10/81)
COUNTY OF LOS ANGELES
U. x t _5/.-3//.Ir7
FOR PERMIT
AIR CONDITIONING
BUILDING AND SAFETY
FOR APPLICANT TO FILL IN
(PRINT OR TYPE ONLY)
BUILDINGQ
ADDRESS
S
'
LOCALITY
`T G
1
NO.
TYPEOF APPLIANCE OR EQUIPMENT
FEE
NEAREST
CROSS ST.
ABSORPTION UNIT, BTU
DISTRICT NO.
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PROCESSM BY
AIR HANDLING UNIT, CFM
BOILER, BTU
APPROVALS
DATE
IN 37 S SIGNATURE
COMPRESSOR, BTU v
/000
ROUGH
FINAL
,
'
,
VALID N
WY1EVAPORATIVE
_
;16 -8 51 A
#000008
1 -41-00
10 0 0 4 1. 0 0 3
o10 4-87
VENTILATION SYSTEM
COOLER
FURNACE: ;AU GRAVTY
FLOOR BTU
n
(/
HEATER: SUSPENDED UNIT
- WALL
c Q d
Plan check fee.
PERMIT"ISSUING FEE $
TOTAL FEE
PLAN CHECK APPLICANT
NAME
ADDRESS
CITY TEL. NO.
`j� �p
OWNER For,a `/�--' %Z
MAIL ADDRESS � 1 Pegs: rn mo 0
CITY 1• C TEL. NO. i i y -Z2,i
CONTRACTOR EWA A`r
ADDRESS i o `'
CITYAAmhLA C TEL. NO.JgJ*
STATE LIC.
LICENSE NO. q7_31429 CLASS C/
SEE REVERSE FOR EXPLANATORY LANGUAGE
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