HomeMy Public PortalAbout5749 PRIMROSE AVE_Mechanical__ WORKER'S COMPENSATION
ate of consent to 7OM46DPW9/89 APPLICATION FOR PERMIT" LIME GREEN
``I hereby affirm that I have•a•certificate of consent to self insure, 78A364C
or a certificate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING
copy thereof(Sec.3800 Lab.C.) u
P❑olicit'No. Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
Certified copy is hereby furnished.
F1Certified9 Inspection ADDRESS
Certified copy is filed with the count building FOR APPLICANT TO FILL IN BUILDING
department. (PRINT OR TYPE ONLY) �i
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($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
Is issued, I shall not employ any person in any manner so as to BOILER,BTU f�
become subject to the Workers'Compensation Laws. 0 �r/
COMPRESSOR.BTU
APPROVALS DATE INSPECTOR'S SIGNATURE
Date ApplicanVENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER e
provisions of the Labor Code,you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU 65- VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 HEATERSUSPENDED UNIT
:
(commencing with Section 7000)of Division 3 of the Business and WALL
Professions Code,
iand
fmy license is in full force and effect.
License Number_C�/ ���Lic.ClassesJQ' `
A!•t•-r t /
51
Contract Date .LIJ� '_-i•�■- C
El❑ Plan check fee � j���W:7-
am exempt under Sec. t 1 1 I: Q
B.&P.C.for this reason PERMIT ISSUING FEE$ CITAL. 146.55
F
Dam TOTAL FEE CHECK' 14*6n5_5 U
S_icnaturer�fr�, PLAN CHECK APPLICANT n CHANGE ISI} U
OWNER-BUILDER DECLARATION a
1 hereby affirm that I am exempt from the Contractor's License Law NAM
for the following reason(Section 7031.5, Business and Professions -$
Code):
El Ize Ii/
_iflLl_i-10[ru 1 ?/ 7/9
ADDRESS/�cp
I, as owner of the property, or my employees with wages �� 1594 1 AM 7:/t-2,
as their sole compensation, will do the work and the CITY�O GC 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.
I hereby affirm that there is a construction lending agency for CONTRACTOR
I performance of the work for which this permit Is issued :L w
(Sec.3097,Civ.C.).
Lender's Name
CITY TEL.N^MX
Lender's Address STATE G LIC.
I certify that I have read this application and state that the above LICENSE NO. 0 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 ins pction purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATURE OF APPLICANT OR AGENT OAS