HomeMy Public PortalAbout6445 TRELAWNEY AVE_Mechanical__ DEC
TION
WORKERS Iha4e COMPENSATION cafe of corse APPLICATION FOR PERMIT
I hereby offurr,that I ha� a certificate of consent to self J�
• Insureoeratertificate of Workers-Compensation Insurance HEATING - VENTILATING - AIR CONDITIONING
or a certlfiedcopythereof (Sec 3800, Lab C ) 76,470{
7D OD46 DPW 9/88
Policy No` Company
Certified copy Is hereby furnished COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with the county building inspec-
tion FOR APPLICANT TO FILL IN BUILDING
• department (PRINT OR TYPE ONLY) ADDRESS14;749451
Date Applicant LOCALITY
NO TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE T CROSS ST L¢/tA Ort/ T,'r/044-w
(This sectlim lMsd trot he :o IOW 1f this Mark Inked by ABSORPTION UNIT BTU 06TRICT NO PROCESSED BY
ti pettish le for one hundrrrd tbllars($100)or Mu) O
I certify that In the performance of the work for which this AIR HANDLING UNIT CFM-
permit
FM t DI
permit is Issued, I shall not employ any person In any manner
so as to become subject to the Workers'Compensah n aws BOILER BTU "tSZO•ALS DATE INSPECTORS SIGNATURE
Dah✓0�0�o Apphca COMPRESSOR BTU ROUGH
NOTICE TO APPLICANT If, r making this Certificate of VENTILATION SYSTEM FINAL
Exemption, you should IWcome subject to the Workers'
Compensation provisions of the Labor Code you must forth EVAPORATIVE COOLER VALIDATION
with comply with such provisions or this permit shall be deem
ed revoked FURNACE FAU GRAVITY
LICENSED CONTRACTORS DECLARATION � FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapteriii HEATER SUSPENDED—UNIT—
(commencing
USPENDED UNIT_(commencing with Section 7000)of Division 3 of the Business MALL
and Profenions Code,and my license is in full force and effect
r
License Number Ltc Class
JJ liGTS k
Contractor Date K
❑ 1 am exempt under Sec - G
Plan check fee
B&P C for this reason d
Date PERMIT ISSUING FEE $ z
Signature TOTAL FEE
OWNER BUILDER DECLARATION PLAN CHECK APPLICANT
1 hereby affirm that I am exempt from the Contractor s License ►
Law for the following reason (Section 7031 5, Business and NAME e,,50 ell LGA
Professions Code)
❑ I, as owner of the property, or my employees with ADDRESS % LA'k�•v
wages as their sole compensation will do the work and
the structure is not intended or offered for sale(Section CITY 7"Gi TEL NO '7�tjD/ +
AC
7044, Business and Professions Code) _CT•'r
F1 as owner of the property am exclusively contracting OWNER ��Cv�'� ��� -347 j,I�IJ
with licensed contractors to construct the project (Sec- AWIRE55 S �� A--U��� 1 ITEM',
7044, Business and Professions Code)
CONSTRUCTION LENDING AGENCY CITY G• r TEL NO �,-� TQTAL 33 � QQ
I hereby affirm that there Is a construction lending agency for _
the performance of the work for which this permit is issued CONTRACTOR
CASH ��•�I
(Sec 3D97, Cw C )
�jH IAIICG .33OTPILLsF ADDRESS t: 7_E .130lenders Name , _ T
AS---7-7 JAG . CITY TEL NO
Lenders Address CI000-ObCli 1��1�I/SYl
1 certify that I have read this application and state that the UCENSE NO LIC
above Information a correct I agree to comply with all County jM 1 Ah O•:G
ordinances and State jaws relating to building construction, v•�c
and hereby authorize representatives of this County to enter
upo the above-mentionedrty for inspection purposes -
SEE REVERSE FOR EXPLANATORY LANGUAGE
&9n tiure of Applicant w Agent Date
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