HomeMy Public PortalAbout9522 WOODRUFF AVE_Mechanical__ ffirm that I have a certificate of coent to YORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
mesa certified`copy thereof(Sec. 38 0, Lab.C.
Insurancelf 76A364C HEATING - VENTILATING - 1AIR CONDITIONING
CE-818(REV. 10/81)
Policy No./O�Og c;?hpany57&rA EVU> I
Certified copy is hereby furnished. COUNTY OF LOS ANGELES I BUILDING AND SAFETY
Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING
tion department. ADDRESS q,5aa LW003>Q�,f-Fr
(PRINT OR TYPE ONLY)
Date///' S aG Applicant 46f"1`44-F--`4 'E"o 12 C4 LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST. %LV�
(This section need not be completed if the work involved by ABSORPTION UNIT;BTU DISTRICT NO. PROCESSED BY
the permit is for one hundred dollars($100)or less.)
I certify that in the performance of the work for which this
AIR HANDLING UNIT,CFM
permit is issued, I shall not employ any person in any manner BOILER,BTU /
.
so as to become subject to the Workers'Compensation Laws. /� APPROVALS DATE IN TOR'S SIGNAT
Date Applicant / COMPRESSOR,BTU O V 061 ROUGH
1
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATIO
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAUI ITY 1
LICENSED CONTRACTORS DECLARATION /' FLOOR BTU O 0 O (j
1 hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
'(commencing with Section 700)of Division 3 of the Business - WALL
and Professions Code,and my license is in full force and effect. • IS
License Number SIe :2 512 Lic. Class G 'ad 11 IIJ
COntractofCLANG&( Pewgft CObte ,p_
❑ •1 am'exempt under Sec. us
us
Plan check fee W-
H
Date:
8.8P.C. for This reason' � �
Signature TOTAL FEE
PERMIT ISSUING FEE$ 1 0 0 9,6 A
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT # o,o 0 0 a 8
I hereby affirm that I am exempt from the Contractor's License ® I o 0 4 3 5 0
Law for the following reason (Section 7031.5, Business and I NAME
Professions Code): o 0 - 435 0 5
❑ I, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and CITY TEL. NO. 0 7.0 7.-8 8
the structure is not intended or offered for sale(Section
7044, Business and Professions Code).
OWNER
❑ I, as owner of the property, am exclusively contracting MAIL
with licensed-contractors to construct the project (Sec- ADDRESS CC 15a-a
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY C.t TEL. NO.
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued CONTRACTOR
(Sec. 3097, Civ. C.). G.L.PrN C, TOWSM co
-JO S. Sl•1- CYL V�
Lender's Name ADDRESS
CITY MO TEL. NO. -3„ 0
Lender's Address
St
STATE LIC.
I certify that I have read this application and state that the LICENSE NO. oa CLASS C_
above 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 t e-m rtN ed property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
-7- S�
Signature of Applicant or Ageewo Date