HomeMy Public PortalAbout5721 OAK AVE_HVAC_2/23/1993_WORKER'S COMPENSATION DEG RAI ON
I hereby affirm that I have a certificate of consen to self Insure,
or a certificate of Worker's Compensation Insuranc 1, or a certified
copy thereof (Sec. 3800 Lab. C.) T
Policy N -F Company +bnrm vf 7-Y,
❑ Certified copy is hereby furnished.
Certified copy is filed with the county building i pection
department. �� y
Date AS 03 ApplicanlT+Qf1G(Qbl_C K
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed If the work involved by the
permit is for one hundred dollars ($100) or less.)
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
become subject to the Workers' Compensation Laws.
20-0046DPW9/99 APPLICATION FOR PERMIT LIME GREEN
20-00 4C
HEATING - VENTILATING - AIR CONDITIONING
COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
FOR APPLICANT TO FILL IN
(PRINT OR TYPE ONLY)
NO. TYPE OF APPLIANCE OR EQUIPMENT
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption, you should become subject to the Workers'. Compensation
provisions of the Labor Code, you must forthwith comply with such
provisions or this permit shall be deemed revoked.
LICENSED CONTRACTORS DECLARATION `
I hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Professions Code, and my license is in full force and effect.
License Number Z � Q q gA Lic. Class
ContracmrNlAfJKf6S F�, Dates/ 3
❑ 1 am exempt under Sec.
B.BP.C. for this reason
Tale:
Signatur-
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law
for the following reason (Section 7031.5, Business and Professions
Code):
❑ I, as owner of the property, or my employees with wages
as their sale compensation, will do the work and the
structure is not intended or offered for sale (Section 7044,
Business and Professions Code).
❑ I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec-
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lendingagency for
the performance of the work for which this permit is issued
(Sec. 3097, Civ. C.).
Lender's Nam -
Lender's Address
I certify that I have read this application and state that the 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 enitehupon the above --mentioned
Z i
51 NATURE OF AP CANT Oe AGENT - / A
ABSORPTION UNIT. BTI I
AIR HANDLING UNIT. CFM
BOILER, BT- I
COMPRESSOR, BTU
VENTILATION SYSTEM
BUILDING
ADDRESS
LOCALITY
FEE
NEAREST
CROSS ST
ASSESSOR
MAP BOOK
NISTRICT NO.
,ROUGH
EVAPORATIVE COOLER , FINAL
FURNACE: (.AHS GRAVITY �i �
FLOOR BTI I l00 AD b �-�/J
HEATER: SUSPENDED UNIT_
WAV.
Plan check fee
PERMIT ISSUING FEE $
TOTAL FEE - Q �,
I.Pfr
APPROVA s
PAGE (PARCEL
PROCESSED BY
DATE INSPECTOR'S SIGNATURE
TAD ION
PLAN CHECK APPLICANT
NAME , V
ADDRESS ACG I .IT
A
CITY
TEL. NO.
3307
501.55
OWNER Pejo L
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MAIL ADDRESS -S 7 z I 64K
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SEE REVERSE FOR EXPLANATORY LANGUAGE
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