HomeMy Public PortalAbout6415 TRELAWNEY AVE_Mechanical__ 20-0046
WORKER SaveCOMPENSATION of consent
76A364DPW 9/ss 'APPLICATION-FON PERMIT LIME GREEN
I hereby affirm that I have a certificate of caneent to self insure 78A384C
or a certificate of Worker a Compensation Insurance or a certified r `;HEATING-VENTILATING -AIR CONDITIONINGcopy ( ac 3800 Lab C)
�I`y No /7Z-O' C01"pe1y— �,` COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV
❑ CertlOed copy Is hereby furnished
�flyT{I�• Certified copy, led with the bulkfinp Inepecuat FOR APPLICANT TO FILL IN BUILDING
lt__ (PRINT OR TYPE ONLY) CRESS
Applicam /may
LOCALITY
NO TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EJ(EMPTION FROM WORKERS NEAREST
COMPENSATION INSURANCE ABSORPTION
ST
I
ABSORPTN UNBTU ASSES
(Tele eactbrt need h not ed compN(ad 0 the Mork Involved by the MAP BOOK PAGE PARCEL
panni(is for one hundred dollen f the or Ieea) AIR HANDLING UNI CFM omiYcr no rRocTsam ar
I candy that in the to Amba an of the work for which this permit
Is become
1 shall not employ any person in any manner so as to BOILER gn
become subject to the Worker Compensation Lowe
COMPRESSOR BTU
rvn.wus w*e rlsrscra+s exvMTurr<
Dale Applicant VENTILATION SYSTEM
NOTICE 70 APPLICANT If eller making this Certificate of ROUGH
Exemption you should become subject to the Workers Compensation )
EVAPORATIVE COOLER
provisions of the Lebo Code you must forthwith comply with each FINAL
provisions or this permit&hall be deemed revoked FURNACE FAU_
LICENSED CONTRACTORS DECLARATION FLOOR Bra VA (DATION
I hereby affirm that I em licensed under provisions of Chapter 9 SUSPENDED UNI_
(commencing with Section 7000) of DMsion 3 of the Business and BEATER WALL
Professions Code and my license Is in full force and effect
License Number Lac CameAV Jan s
AULT }
can
�G7 1C19. a
F-1I am exempt under Sec Plan Check fee 1 ITEMS2
B&P C for this meecrt PERMIT ISSUING FEES TOTAL 109 . 55 0
Date TOTAL FEE CHECK 109.55 W
Signature d
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT _ CHANGE .IN Z
I hereby affirm that I em exempt from the Contractor a License Law NAME
for the following reason(Section 7031 5 Business and Professions
Code) ADDRESS CACI-UCS 1 9/17/9`
❑ 1 as owner of the property or my employees with wages 5519 1 AN10*20
as their sole compensation will do the work and the CITY TEL NO
structure 1& not intended or offered for sale (Section 70"
Business and Professions Code) OWNER
��
❑ 1 as owner of the property em exclusively contracting �6
with licensed contractors to construct the project (Sec
MAL
N44 on 70Business and Professions Code)
CONSTRUCTION LENDING AGENCY CITY TEL NO
I hereby affirm that there Is a construction lending a6a ency for CONTRACTOR �� 1 ,
the performance of the work for which this permit lissued _
(Sec 3087 Civ C) / �, f.+ /�
AODRFS,S
Lender a Nemo
Of; TEL
Lender a Address STATE &C
1 certify that I have read this application and state that the above STATE E No �, cu9,R
mformatlan correct I agree to comply with all County unummcea
and State relating to builWng construction,and hereby au0nonze
re Ir 1 this County to enter upon the above n timed
P
in o purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
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