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HomeMy WebLinkAbout1503A (8)DEC TION WORKERS' t I have a certificate cafe of corse APPLICATION FOR PERMIT. I hereby affirm that I have r certificate of consent to self /� ` �( ),3,7/9 f 9 insure, oro certificate of Workers' Compensation Insurance, 76A3e4c - HEATING - VENTILATING - AIR CONDITIONING i �%{�j�err{fi%,,d/copy ereyf (Sec. 38 ,Lab. C. CE - eia(REV. iom) --- - -- - -"-- " - Pd if cy Nb'" r y/'' Compgn ❑ Certified'copy is hereby furnished.COUNTYOFLOS ANGELES - BUILDING AND SAFETY —* 309-6 I/( Cerfified copy isfiledwith the county building inspec. 1,— tion department. . �. -}f-� DatefU-/d' 7 7AppIicant c -_x_ CERTIFICATE OF EXEMPTION FROM W KERS'. -- - COMPENSATION INSURANCE (This section nneed not be completed if the work Involved by - }he permit is for one hundred dollars ($100) or less.) I certify that In the performance of the work for which this permit is issued, 1 shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws. .- 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 forth- with comply with such provisions or this permit shall be deemed revoked. LICENSED CONTRACTORS DECLARATION - hereby affirm that I am licensed under provisions of Chapter9 `(commencing with Section 7000) of Division 3 of the Business and Professions Code, end my license is in full force and effect. License Number //Lic. Class Contracto -11A6 Daje /O ❑ I am exempt under Sec. B.BP.C. for this reason. Signature - OWNER -BUILDER DECLARATION - I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7.031.5, Business and Professions Code): - ❑ I, as owner of the property, or my employees with _ wages as their sole 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 constructthe project (Sec- - tion 7044, Business and Professions Code). - CONSTRUCTION LENDING AGENCY - I hereby affirm that there Is a construction lending agency for the performance of the .work for which this permit is issued (Sec. 3097, Civ. C.). - 'Lender's Name Lender's Address I certify that I have read this application and state that the - FOR APPLICANT TO Flll IN (PRINT OR TYPE ONLY) none ss NO. TYPE OF APPLIANCE OR EQUIPMENT - FEE LIDCALITY !/ stC _L_. NEAREST CROSS ST. _ ABSORPTION UNIT, BTU DISTRICT NO. PROCESSED BY AIR HANDLING UNIT, CFM BOILER, BTU APPROVALS DATE - INSPECTOR'S SIGNATURE COMPRESSOR, BTU ROUGH p - VENTILATION SYSTEM FINAL 81� EVAPORATIVE COOLER Poo....7.75 , - VALIDATION ;E 1 5 G3 A # • • • • • 8 ( • -74.75 - 1 R21 -87 - FURNACE:FAU GRAVITY / _ FLOOR BTU HEATER: SUSPENDED WALL Plan check fee PERMIT ISSUING FEES D S O TOTAL FEE 7 g PAN CHECK APPLICANT NAME � ADDRESS CITY TEL. NO. OWNER a.L� MAIL Z, ... - ._. ADDRESS C- CITY .TEL. PA.... _. _. __...... CONTRACT p " " ADDRESSa3 CITY©" STATE G LICENSE NO. /�..__ -.CASS . (,�'-2.D 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 the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE 16 -any 7 Signature of Applicant or AgJI Date