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Home My Public Portal About5327 WELLAND AVE_Mechanical__ ION 2MO 1k 0 'WORKER'S I have certificate of consent to 7BA346DPW9/89 APPLICATION FOR PERMIT LI EGREEK 76A364C I hereby affirm that I have a certificate of consent to self insure, or a c.rflflcite of Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING cry thereof(Sec.3800 Lab.C.) Z Policy No.VA ' Co p0O COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV. ❑ Certified copy is hereby furnished. _11-11-SC-1103 Certified copy is filed with the county building inspection _ FOR APPLICANT TO FILL IN BUILDING ep rtment. 99 g I pp1/�s►A (PRINT OR TYPE ONLY) ADDRESS 7 Dat plican= -!�/ .� LOCALITY iNO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST COMPENSATION INSURANCE CROSS ABSORPTION UNIT,BTU ASSESSOR (This section need not be completed If the work Involved by the MAP BOOK PAGE PARCEL permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO. PROCESSED BY I certify that in the performance of the work for which this permit Is issued, I shall not employ any person in any manner so as to BOILER,BTU become subject to the Workers'Compensation Laws. v v Qs, COMPRESSOR,BTU APPROVALS DATE INSPECTOR'S SIGNATURE Date Applicant VENTILATION SYSTEM NOTICE TO APPLICANT: If, after making this Certificate of I ROUGH Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER provisions of the Labor Code, you must forthwith comply with such I FINAL provisions or this permit shall be deemed revoked. FURNACE: FAU LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATION I hereby affirm that I am licensed under provisions of Chapter 8 SUSPENDED UNIT (commencing with Section 7000)of Division 3 of the Business and HEATER: WALL Professions Code,and my licennsee Is in full force and effect. Za f� 0 License Numbeg/ 147 ns` Lia Class °r CL Contra F1I am exempt under Sec. Plan Check fee G B.&P.C.for this reason PERMIT ISSUING FEE$ 5,1, 1-- Date: TOTAL FEE �� C Signature a . OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT 0- G 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 W :1�-. 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, - I _ - -- - .l:Iii. Business and Professions Code). OWN E —• -r ❑ I, as owner of the property, am exclusively contracting MAIL 7 with licensed contractors to construct the project (Sec- ADDRESS n tion 7044, Business and Professions Code). CITY TEL.NO. t•I':1 T CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for CONTRALTO , the performance of the work for which this permit Is Issued I•• -1,t_w ;a - s'; (Sec.3097,Civ.C.). :=_)_ "I.•.•_ a =! jADDRES _Lender's Name `"NLender's Address ATE 2'7/ LICI certify that I have read this application and state that the above ENSE N /(� CLASSC.i information is correct. I agree to comply with all County ordinances and State laws relating to building construction,and hereby authorize represents•ves of this County to enter upon th above-mentioned property inspection urppses. SEE REVERSE FOR EXPLANATORY LANGUAGE SIGNMYRE OF APPLICANT OR AGENT DATE