HomeMy Public PortalAbout5434 PERSIMMON AVE_Mechanical__ ION
WOthat I have
a certificate
of consent to 76A36sDPW 9/89 APPLICATION FOR PERMIT LIME GREEN
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I hereby affirm that I have a certificate of consent to self insure,
or a 6drtificate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING
cefyiy thereof(Sec.3800 Lab.C.)
�
cy No. Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
Certified copy is hereby furnished.
❑ Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN BUILDING
ADDRESS ��3
department. (PRINT OR TYPE ONLY) 4-'
LOCALITY
Date Applicant
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
CROSS ST.
COMPENSATION INSURANCE ABSORPTION UNIT,BTU
(This section need not be completed if the work Involved by the ASSESSOR
MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO. PROCESSED Y
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU E.
O1—Nr'�6r
become subject to the Workers'Compensation Laws.
COMPRESSOR,BTU 46"1 O
.0- r APPROVALS DATE 1 GNATURE
Date d ` Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after makIqJ this Certificate o ROUGH
Exemption,you should become subject to th Workers'Compensation EVAPORATIVE COOLER _
provisions of the Labor Code,you must forthwith comply with such FINAL g
provisions or this permit shall be deemed revoked. FURNACE: FAU y GRgVITYt 2�p VALIDATION
LICENSED CONTRACTORS DECLARATION FLOOR BTU .7-p-
I hereby affirm that I am licensed under provisions of Chapter 9 HEATERSUSPENDED UNIT
:
(commencing with Section 7000)of Division 3 of the Business and WALL
Professions Code,and my license is in full force and effect.
33 ��
License Number A Y Lic.Class Z0
LL C
Contractor �O ��L7r crJdJiate s
ElI am exempt under Sec. Plan check fee
13
B.&P.C.for this reason PERMIT ISSUING FEE$ 2-7 3� F
Date: TOTAL FEE t4 13
Signature a
PLAN CHECK APPLICANT
OWNER-BUILDER DECLARATION e
1 hereby affirm that I am exempt from the Contractor's License Law NAME ,
for the following reason(Section 7031.5, Business and Professions /
Code): ADDRESS ACCT a T
1, as owner of the property, or my employees with wages
0� 1 f(
as their sole compensation, will do the work and the CITY TEL.NO.
.10
structure is not intended or offered for sale(Section 7044, • 1 ITEMS
Business and Professions Code). OWNER
I, as owner of the property, am exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRESS �yJ / ,,/�( CHECK 114e��
tion 7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY �° Z- TEL.NO.pi�`lFo� CHANGE .00
I hereby affirm that there is a construction lending a ency for r
p p CONTRACTOR 5\/ p� �
the eriormance of the work for which this permit is issued o nnnn nnni
(Sec.3097,Civ.C.). ADDRESS j✓ 7 1r� 0000-0001 10/16/95
Lender's Name I/ �p� ]0019 1 A�11;ir-J
CITY m l„fI9 8,4 TEL.NO. rp,
Lender's Address. �7
I certify that I have read this application and state that the above LICENSE NO. 7 ? CLASS
information is correct. I agree to comply with all County ordinances
and State laws relating to building construction,and hereby authorize
representatives of this County to enter upon the above-mentioned
property for inspeo ion purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
STGNATU;VF APPUCMTOR AGENT ATE