HomeMy Public PortalAbout9610 VAL ST_Mechanical__ WORKER I h8vo a certificate
DECLARATION 7OA35 DPW Wall APPLICATION FOR PERMIT LIME GREEM
I hSreby affirm that I have a certrticete of ooneant to Bell Insure 7t>a36CC
l` or a certdwate of Worker a Compensation insurance or a certified HEATING-VENTILATING-AIR CONDITIONING
I) copy thereof(Sac 3800 Lab C)
/ Policy No Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV
❑ Candied copy is hereby fumished
❑ Certlfled copy m filed with the county building inspecixm FOR APPLICANT TO FILL IN BUILDING
department (PRINT OR TYPE ONLY) ADDRESS
Date Applicant LOCALITY
NO TYPE OF APPLIANCE OR E(N1IPMEN7 FEE
CERTIFICATE OF EXEMPTION FROM WORKERS NEAREST
COMPENSATION INSURANCE CR()69 ST
ABSORPTION UNIT BTU ASSESSOR
(This t Issectionr nab not be completed($1 If iM work Involved 6y the MAP BOOK E PARCEL
permit M for one hundred dollars(f 100)a leu) AIR HANDLING UNIT CFM PwmCrrq p�eam e�.
I certify that In the performance of the work (or which this permit
Is Issued I shell not employ any person in any manner so as to BOILER BTU n�
become eubje t to a Workers Compensation Lawn (/
COMPRESSOR BTU �oO
Date Applrranl rsmovus DATE saw silxmuruxe
N OTIC O P ICANT If alter ma g ertllroete of VENTILATION SYSTEM ROUGH
Exam h n /
p you should become subject to the Workers Compensation EVAPORATIVE COOLER
provisions of the Labor Code you must forthwith comply with such FINAL
provisions of this permit shall be deemed revoked FURNACE FAU ORA
LICENSED CONTRACTORS DECLARATON FLOOR BTU VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER SUSPENDED—UNIT—
(commencing
USPENDED UNIT_(commencing with Section 70011) of Division 3 of the Business and WALL
Profeemonn Code and my license in In full force and effect
i
License Number LIC Gass O ACCT.r
r
Victor ale 3 �.�•�- x'303 114.100
I am Me Mpt neer sec Plan check fee 1 ITEMS U
B dP C for this reason PERMIT ISSUING FEE$ p TOTAL 114 - 100
�,�'pa. Daatt9/.�� TOTAL FEE D CASH 114.10
114,10 w
Rlnneliw�64// �� / PLAN CHECK APPLICANT y` A� .00 �
OWNERAUI LER CLARAnON Z
I hereby affirm that I am exempt from the Contractors License Law NAME ,
for the following reason (Section 7031 8 Business and Professions 0000-0001 7/ 3/95
Code)
F1 as owner of the property or my employees with wages 1150 1 AN10.51
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 Profeenlons 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 /
I hereby affirm that there Is a construction lending agency for ,
the performance of the work for which this permit Is issued WmTiAcm v
(Sec $097 CW C) p
ADDRESS
Lender a Name
CITY TEL N , �
Lenders Address STATE / '�f LA _
I certity that I have read this application and state that the above LICENSE NO tJ V SS
Information Is correct I agree to comply with all County ordinances,
and State laws relating to building coretnlctlon and hereby authorize
representatives of this County to enter cellon the abovetrtentlonadl r
properly to pectlon purposes BEE REVERSE FOR EXPLANATORY LANGUAGE