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Home My Public Portal About5325 ZADELL AVE_Mechanical_8/12/1992_ ION WORKER'S I have a certificate of consent to 7SA364 DPW 9189 APPLICATION FOR PERMIT LIME GREEN 76A364C I hereby affirm that I have a certificate of consent to self Insure, or a certificate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING copy thereof(Sec.3800 Lab.C.) Policy No. Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV. ertified copy is hereby furnished. Certified copy is filed with the county building Inspection FOR APPLICANT TO FILL IN BUILDING 2 _Z2 J IN 6L department. (PRINT OR TYPE ONLY) ADDRESS Date Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST COMPENSATION INSURANCE CROSS ST. (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. 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. / f!t7 ��-rrnn COMPRESSOR,BTUZ. APPROVALS DATE INSP R'S SIGNATURE Date ~��` Applicant J Qg1,"[l/!cI;2 VENTILATION SYSTEM NOTICE TO APPLICANT: If, after making this Certificate of ROUGH Z 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 GRAVITY LICENSED CONTRACTORS DECLARATION FLOOR BTU / VAL A ION I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED—UNIT— (commencing USPENDED UNIT(commencing with Section 7000)of Division 3 of the Business and HEATER: WALL Professions Code,and my license is in full force and effect. > License Number �`f b-� Lic.Class Contractor— / h 911,P>l[le Data —1 Z �� , C ❑ I am exempt under Sec. Plan check fee CQ B.&P.C.for this reason PERMIT ISSUING FEE$01 3 ., Date: �Z—�/ TOTAL FEE �.p L Signature j�.l n �` CLU O PLAN CHECK APPLICANT Cf 1 hereby affirm that 1 am exempt from the Contractor's License Law NAME 5 , for the following reason (Section 7031.5, Business and Professions - Code): ADDRESS Z d r•r-- a I, as owner of the property, or my employees with wages as their sole compensation, will do the work and the CITY TEL.NO. �• Ijr °11_ structure is not intended or offered for sale(Section 7044, r I� Business and Professions Code). OWNER 1 L t:3. ❑ 1, as owner of the property, am exclusively contracting MAILZ 01 AL 59 00with licensed contractors to construct the project (Sec- ADDRESS It tion 7044, Business and Professions Code). 9 f CHECK c .01-- ONSTRUCTION LENDING AGENCY CITY TEL.NO. -- I hereby affirm that there is a construction lending agency for —( , CHANGE the performance of the work for which this permit Is issued CONTRACTOR 'le (Sec.3097,Civ.C.). ADDRESS ,� Lender's Name 030.0--1-Llil _r• -: 'f i 'i CITY TEL.NO. QJq l — / � t',=.- r' ,4 (� Lender's Address ° t : I certify that I have read this application and state that the above LICENSE NO. ��j CLASS information is correct. I agree to comply with all County ordinances and State laws relating to building construction,and hereby authorize representatives of tl}is County to enter upon the above-mentioned property for insapetion puurrpp as. // SEE REVERSE FOR EXPLANATORY LANGUAGE -12- SIGNATURE CSIGNATURE OF APPLICANT R-AG T ATE