HomeMy Public PortalAbout5639 PERSIMMON AVE_Mechanical__ - � °y11/JfPKER'SCPMPENSATIONDECLARATION �6A364CPW9/89 APPLICATION FOR PERMIT LIME GREEN
I Thereby a(rfirm that I have a certificate of consent to self insure,
er a certificate'ot•Walker's Compensation'Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING
copy thereof(Sec.3800kab.CY�jj
Policy No.'7 r+- mpany -v - COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
❑ Certified copy is hereby furnished.
Certified co is filed with the co building In ec' FOR APPLICANT TO FILL IN BUILDING /M
copy 9 P ADDRESS Jv
department.n (PRINT OR TYPE ONLY)
Date .--- .--L6r Applicant LOCALITY r �
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
NEAREST )g � �,�y� 11 Qr�
CERTIFICATE OF EXEMPTION FROM O KERS' CROSS ST. `�I V't--- tSin
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 NOPROCESSED 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 �D p
become subject to the Workers'Compensation Laws. O
COMPRESSOR.BTU
APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code,you must forthwith comply with such jr FINAL
provisions or this permit shall be deemed revoked. popFURNACE: FAU It GRAVITY VALIDAT ON;
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT
(commencing with Section 7000)of Division 3 of the Business and EATER: WALL
Professions Code,and my license is in full force and effect. qq
License Numb W�y Lic.Class / -
tt o
Contractor Date � ' 1 + r-•+• h
❑ Plan check fee fit': . i �
I am exempt nd Sec. ; -
B.&P.C.for this re n PERMIT ISSUING FEE O CHANGE
Date' TOTAL FEE hD _
Signature ® h.l:l_I -il�l�'i s �.�:`' • C
PLAN CHECK APPLICANT .- , 01111-21■'','
OWNER-BUIL R D CLARATION 34 jr_`. _ "-- e
I hereby affirm that I am exemp the Contractor's License Law NAME
for the following reason(Section 7031.5, Business and Professions
Code): ADDRESS
❑ 1, as owner of the property, or my employees with wages
as their sole compensation, will do the work and the CITY TEL.NO. ,
structure is not intended or offered for sale (Section 7044,
Business and Professions Code). OWNER
❑ 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).
CONSTRUCTION LENDING AGENCY CITY TEL.NO.
Ihereby affirm that there is a construction lending agency for CONTRACTOR
the performance of the work for which this permit Is issued
(SBC.3097,Civ.C.).
ADDRESS S71�
Lender's Name �6
CITY TEL.NO.
r
Lender's Address STATE J LIC.
I certify that I have read this application and state that the above LICENSE NO. ® � CLASS
information is correct. I agree to comply with all County ordinances
and St a laws relating to building construction,and hereby authorize
repre ntatives of this Count to enter upon the above-mentioned
pro f map tion p o s. 01 SEE REVERSE FOR EXPLANATORY LANGUAGE
SI ATURE OF APPL AN OR AGENT DATE