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Home My Public Portal About5415 PERSIMMON AVE_Mechanical__ VVUKr, IL)N affirm that ',.I have JA erti tate of cons APPLICATION FOR PERMIT I.hereby affirm that I have a certificate of consent to self >'irisure, or a certificate of Workers' Compensation Insurance, HEATINGVENTILATING - AIR CONDITIONING or a certified copy thereof (Sec. 3800, Lab. C.) ,76A36�4C 20-0046 DIN 9/88 policy i O. Company COUNTY OF LOS ANGELES BUILDING AND SAFETY Certified copy is hereby furnished. c ❑ Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING 1�q 1� tion department. (PRINT OR TYPE ONLY) ADDRESS 'IZDate Applicant LOCALITY NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST COMPENSATION INSURANCE CROSS ST. (This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO. PROCESSED BY the permit is for one hundred dollars(;100) or less.) I certify that in the performance of the work for which this AIR HANDLING UNIT, CFM permit is issued, I shall not employ any person in any manner so as to becomesubjectto the Workers'Compensation Laws. BOILER, BTU APPROVALS DATE INSPECTOR'S SIGNATURE Date g e� r� Applicant�� "��\ / COMPRESSOR, BTU �� ROUGH `iv NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL Z Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION with comply with such provisions or this permit shall be deem- ed revoked. / FURNACE: FAU GRAVITY LICENSED CONTRACTORS DECLARATION FLOOR BTU 191610�— /;;1– 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 WALL and Professions Code,and my license is in full force and effect. } License Number Lic. Class0 0 Poo u Contractor Date 0 ❑ I am exempt under Sec. _ O Plan check fee u B.BP.C. for this reason H Date: PERMIT ISSUING FEE $ Signature TOTAL 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 7031.5, Business and NAME Professions Code): ❑ I, as owner of the property, or my employees with ADDRESS wages as their sole compensation,will do the work and CITY TEL. NO. the structure is not intended or offered for sale(Section �. 7044, Business and Professions Code). 4 ACCT.4 °g ❑ I, as owner of the property, am exclusively contracting OWNER P � I. s°i_ with licensed contractors to construct the project (Sec- MAIL �� \ ''307 I tion 7044, Business and Professions Code). ADDRESS + •�s-K: ) 1 i1�;:L CONSTRUCTION LENDING AGENCY CITY TEL. NO. 2 I hereby affirm that there is a construction lending agency for ® T TTL 5 C30 the performance of the work for which this permit is issued CONTRACTOR CHIEECK (Sec. 3097, Civ. C.). Lender's Name ADDRESS CHAN',E °! • CITY TEL. NO. Lender's Address _ _- I certifythat I have read this application and state that the STATE LIC. I:uI3134'1010I IC/ �i'`'I: PP LICENSE NO. CLASS above information is correct. I agree to comply with all County ° ordinances and State laws relating to building construction, 311 4 Z Al"!s`I°D' and hereby authorize representatives of this County to enter g1%on the above-me 'oned property for inspection purposes.. SEE REVERSE FOR EXPLANATORY LANGUAGE ignature of Applicant or Agent Date �9 •WORKER'S COMPENSATION DECLARATION 20.0046 DPW 8/89 GEi'hxreby affirm that I have a certificate of consent to self Insure, APPLICATION FOR PERMIT76A384C LIMV or a certificate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING copy thereof(Sec.3800 Lab.C.) Policy No. Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV. {❑ Certified copy is hereby furnished. BUILDING L=1 Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN ADDRESS department. C r- (PRINT OR TYPE ONLY) Date Z IV-q"kpplicant \ LOCALITY NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST CROSS ABSORPTION UNIT,BTU COMPENSATION INSURANCE OR °� �Q (This section need not be completed If the work involved by the MAP BOOK loG PAGE PARCEL permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO. PROCESSED BY I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to BOILER.BTU a become subject to the Workers'Compensation Laws. COMPRESSOR,BTU APPROVALS DATE INSPECTOR'S SIGNATURE Date 7" Applicant - r�a{Ai11 AJ1Q 9YSTEM NOTICE TO APPLICANT: If, after making this Certificate of 9 -`` 7 ROUGH - Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER provisions of the Labor Code,you must forthwith comply with such FINAL provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDA ION I hereby affirm that 1 am licensed under provisions of Chapter 9 SUSPENDED UNIT (commencing with Section 7000)of Division 3 of the Business and HEATER: WALL Professions Code,and my license is in full force and effect. License Number Lic.Class V DCCT o 0 c Contractor Date Plan check fee 3307 58.35 C I am exempt under Sec. C BAP.C.for this reason PERMIT ISSUING FEE$ , 1 ITEMS C Date: _ TOTAL FEE TOTAL 58.35 u Signature CHECK; 58.35 U. PLAN CHECK APPLICANT n OWNER-BUILDER DECLARATION CHANGE .011 � 1 horeby affirm that I am exempt from the Contractor's License Law NAME 9` ` ® r7Ki� for the following reason (Section 7031.5, Business and Professions Code): ADDRESS [ F1I, as owner of the property, or my employees with wages �`��cyf.S 1]13130_0001 2ft 14/?3 as their sole compensation, will do the work and the CITY `•Gt TEL.NO. � 4'i82i � i Att111�4 � ructure is not intended or offered for sale(Section 7044, Business and Professions Code). OWNER i I, as owner of the property, am exclusively contracting MAIL with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code). CITY TEL.NO. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for CONTRACTOR the performance of the work for which this permit Is issued (Soc.3097,Civ.C.). ADDRESS Lend•:is Name CITY TEL.NO. Lender's Address STATE LIC. I certi,y that I have read this application and state that the above LICENSE NO. CLASS inform ition is correct. I agree to comply with all County ordinances and Slate laws relating to building construction,and hereby authorize representatives of this County to enter upon the above-mentioned p arty for-ins p tioi sea. SEE REVERSE FOR EXPLANATORY LANGUAGE NATURE OF APPL CANTOR AGENT DATE