HomeMy Public PortalAbout5756 RIO HONDO AVE_Mechanical__ ION
WORKER'S I have
a certificate
of consent to 78A34aDPW9/as APPLICATION FOR PERMIT LIME GREEN;
76A384C
I hereby affirm that I have a certificate of consent to self insure,
or a certificate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING
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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.
❑ Cdepartment. (PRINT OR TYPE ONLY) DING
ertified copy is filed with the county building inspection FOR APPLICANT TO FILL IN ADDRESS
Date Applicant LOCALI e
NO. TYPE OF APPLIANCE EQUIPMENTi'r t FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE AB•' ori �"� r CROSS /
ABSORPTION UNIT,BTU ASSESSOROR 3fi•� �[_
(This section need not be completed if the work involved by the MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY �/dJ661-
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1 certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU
become subject to the Workers'Compensation Laws.
COMPRESSOR,BTU R= 4 �D
APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION / FLOOR BTU VA I ATION
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED-UNIT
(commencing
USPENDED UNIT(commencing with Section 7000)of Division 3 of the Business and HEATER: WALL
Professions Code,and my license is in full force and effect. C.
/►
License Number Lic.Class ��'Q �� _
�1 G
Contractor Date C
❑ I am exempt under Sec. Plan Check fee
B.&P.C.for this reason PERMIT ISSUING FEE$ �Sv C C
Date: TOTAL FEE �i t- .�- a W
ACCTA 0.
Signature PLAN CHECK APPLICANT( 75.45 cc
OWNER-BUILDER DECLARATION ITEM
h1
I hereby affirm that I am exempt from the Contractor's License Law NAME , 1 T!E 1S
for the following reason(Section 7031.5, Business and Professions ���...JJJ �.
VCode' ADDRESS + TOTAL 751 e
I, as owner of the property, or my employees with wages
as their sole compensation, will do the work and the TEL.NO. gin CHECK 10 aic
li
structure is not intended or offered for sale(Section 7044, CHANGE .Oc(
Business and Professions Code). OWNER
❑ I, as owner of the property, am exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRESS ,-y I ' 12/93
tion 7044,Business and Professions Code). ) 1� Q-,� 11�
CONSTRUCTION LENDING AGENCY CITY TEL.NO. 9163 1 AM 8-14
1 hereby affirm that there is a construction lending agency for CONTRACTOR 11110.the performance of the work for which this permit is issued
(Sec.3097,Civ.C.).
ADDRESS
Lender's Name
CITY TEL.NO.
Lender's Address STATE,,-' LIC.
I certify that I have read this application and state that the above LISWSE NO. 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 inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
e,OATUR OFAPPU? AGE DATE