HomeMy Public PortalAbout9887 WENDON ST_Mechanical__ ION
ti WORKER'S I have
a certificate
of consent to 200048 DPW 9/89 APPLICATION FOR PERMIT LIME GREEN
76A3e4C
I hereby affirm that I have a certificate of consent to self insure,
or a certf!icate of Worker's Compensation Insurance, or a certified I HEATING-VENTILATING-AIR CONDITIONING
copy there�fi€(Sec.3800 Lab.C.)
Policy No. Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
❑ Certified'copy is hereby furnished. '
❑ Certified co is filed with the county building inspection FOR APPLICANT TO FILL IN BUILDING �� D '
copy g p ADDRESS
department. I (PRINT OR TYPE ONLY)
LOCALITY
Date Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
NEAREST Ir
CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST.
COMPENSATION INSURANCE ABSORPTION UNIT,BTU
(This section need not be completed if the work Involved by the ASSESSOR
MAP BOOK' PAGE PARCEL
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROC BY
I certify that in the performance of the work for which this permit r�
is Issued, I shall not employ any person in any manner so as to BOILER,BTU ft(JX
become subject to the Workers'Compensation Laws. I 0
COMPRESSOR BTU /
APPROVALS DATE INSPECTOR'S SIGNATURE
Data = ipplicant VENTILATION SYSTEM
NOTICE TO APP ICA f If, aking this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER - "
provisions of the Labor Code,you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU e GRAVITY
LICENSED CONTRACTORS DECLARATION. ; FLOOR BTU VALIDATION
I hereby affirm that 1 am licensed under provisions of Chapter 9 HEATER; SUSPENDED-UNIT-
(commencing
USPENDED UNIT(commencing with Section 7000)of Division 3 of the Business and i WALL
Professions Code,and my license is in full force and effect. ;
n/� I
License Number (f/ Lic.Class
i
Contract Date C
❑ I am exempt under Se . Plan check fee Q
B.&P.C.for this reason I PERMIT ISSUING FEE$,01-;3 C
Date: I TOTAL FEE Q D
Signature
PLAN CHECK APPLICANT co
OWNER-BUILDER DECLARATION t
I hereby affirm that I am exempt from the Contractor's License Law NAME
for the following reason (Section 7031.5, Business and Professions
ADDRESS �
Code): �- s
❑ [t::•t o a - ,
1, as owner of the property, or my employees with wages
as their sale compensation, will do the work and the CITY TEL.NO. �• ir' ,'i;}�iltj
structure is not intended or offered for sale(Section 7044, J 4
�,_
Business and Professions Code). OWNER l !til i•ti
I, as owner of the property, am exclusively contracting MAIL `' (I,(I(�L 37 m 00
with licensed contractors to construct the project (Sec- ADDRESS b
tion 7044,Business and Professions Code). / ,:°IrECK 1;,x.111
CONSTRUCTION LENDING AGENCY CITY TEL.NO.
I hereby affirm that there is a construction lending agency for ® �Hf;ME
the performance of the work for which this permit is issued CONTRACT
(Sec.3097,Civ.C.).
ADDRESS
Lender's Name � °���"�� 1�1�1�� '���•s�ff�'
CITY , TEL.NO.OW&I �.,, --
10
Lender's Address
I certify that'I have read this application and state that the above ILCETNSE NO. S (} CLCASS C�
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 for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
I E OF AP CANTOR AGENT DATE