HomeMy Public PortalAbout5615 SANTA ANITA AVE_Mechanical__ ION
WORKER'S I have
a certificate
of consent to �l�PW 9l89 APPLICATION FOR PERMIT LIME GREEN
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
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 furnise/untuilding
/r
FJ Certified copy is filed with the inspection FOR APPLICANT TO FILL IN ADDRESS
department. (PRINT OR TYPE ONLY) C
Date Applicant LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMP N FROM WORKERS' NEAREST.
ST.
COMPENSATI I SURANCE ABSORPTION UNIT,BTU mac–'
(This section need not be cam late if the work involved by the MAP BOOK �J j PAGaz PARCEL lite
permit Is for one hundred dollars($ 00)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESS Y
I certify that in the performance of t e work for which this permit ,u
is issued, I shall not employ any person in any manner so as to BOILER,BTU-
become
TU become subject to the Workers'Compensation Laws. Oi rr�� °
COMPRESSOR,BTU o
1 APPROVALS DATE INSPEC S SIGNATURE 131
Date ` pplicant ev VENTILATION SYSTEM
NOTICET6 APPL CAN : If, after aking this Certific of ROUGH ,V
Exemption,you should become subjec o the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code,you must forthwith comply with such FINAL
provisions or this
LICENSED CONTRACTORS DECLARATION FLOORCE: FAU BTU GRAM Os 4_0
VALIDATION
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1 hereby affirm that I am licensed under provisions of Chapter 9 HEATERSUSPENDED UNIT y::A�,s �F
:
(commencing with Section 7000) of Division 3 of the Business and WALL
Professions Code,and my license Is in full force and effect. (I =f:`i,y!
License NumberLlo.Class L� ;0 ���� � I ��i,,',,.._,,_
/ m O� lol- TOTAL ,:�23 o 80 a
Contractor `+ wImitr/���f�—^atg CHE"11 k -�a�`:I
❑ I am exempt under Sec. Plan Check fee '.•liANGE e �C
B.&P.C.for this reason PERMIT ISSUING FEE$ Q (F.
Date: TOTAL FEE i.I1100—[0111 5/3 11/94 a
Signature OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT r�t )1 7° '
I 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
❑ I, 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 j — Co/V D -
❑ I, as owner of the property, am exclusively contracting MAIL f
with licensed contractors to construct the project (Sec- ADDRESS I
tion 7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY /4 M2�. TEL.NO.
I hereby affirm that there is a construction lending agency for CONTRACTOR ;
the performance of the work for which this permit Is Issued ,5 C h -
(Sec.3097,Civ.C.).
ADDRESSW /�0
Lender's Name y
CITY VT TEL.NO.
Lender's Address STATE 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 State laws relating to building construction,and hereby authorize
representatives of this County to enter upon the above-mentioned
property fo inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
3q 4
SIGNATMAE OF APPLICANT 0R AGEI T DATE