HomeMy Public PortalAbout4839 ARDEN DR_Mechanical__ Vm that I S COMPENSATION DECLARATION 76A366 DPW 9,69 APPLICATION FOR PERMIT LI E GREEP111,
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 NO13N LIQ 6�1"Company R (�S V COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
❑ Certified copy is hereby furnished.
Certified co is filed with the coup ildin iGnspection FOR APPLICANT TO FILL IN BUILDING t 1 �� .�
de artm ntPy g p (PRINT OR TYPE ONLY) ADDRESS Iv
Date Applicant LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTIO OM WORKERS' NEAREST
CROSS ST.
COMPENSATION INSURANCE ABSORPTION UNIT,BTU
(This section need not be completed if the work involved.by the ASSESSOR
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT OOK AG PARCEL
PROCESSED ev
I certify that in the performance of the work for which this permit
is /
issued, I shall not employ any person in any manner so as to BOILER,BTU
become subject to the Workers' Compensation Laws. -7 9
COMPRESSOR,BTU 4�
APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL �L6�
provisions or this permit shall be deemed revoked. FURNACE: FAU I GRAVI Y '
LICENSED CONTRACTORS DECLARATION FLOOR BTU- VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9SUSPENDED UNIT
(commencing with Section 7000) of Division 3 of the Business and HEATER: WALL
Professions Code,and my license is in full force and effect. b `N
License Number 5 Lic.Class yr w
Contractor Date 2 Z
❑ Plan check fee 0
I am exempt under Sec.
B.&P.C.for this reason PERMIT ISSUING FEE$ /: p Q O
Date: TOTAL FEE O W
Signature d
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT (n
Z
I hereby affirm that I am exempt from the Contractor's License Law NAME ,
for the following reason (Section 7031.5, Business and Professions -
Code): ADDRESS
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❑ °3
I, as owner of the property, or my employees with wages
as their sole compensation, will do the work and the CITY TEL.NO. :-", r'1 `f
p L!i _ L.structure is not intended or offered for sale (Section 7044, �� 1
Business and Professions Code). OWNER (.� e VJaw0- ( t o I, S YV v �" €�w°
❑ I, as owner of the property, am exclusively contracting MAIL f vVV4j { �„
with licensed contractors to construct the project (Sec- ADDRESS B 3® I 0. t V pt�� _
tion 7044, Business and Professions Code). !''HE(:i Ji'
CONSTRUCTION LENDING AGENCY CITY V 8Q t I L.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.).
ADDRESS M
Lender's Name A �� nn rr,�� 1-1
�y `' .
CITY�Y^" A 1� Y V TEL:NO. ( b��'ah e'D
c y-:
Lender's Address STATE Q LIC. /1
I certify that I have read this application and state that the above LICENSE NO. �b S C3 CLASS-
information
LASS information is correct. I agree to comply with all County ordinances
andStat .laws relating to building construction,and hereby authorize
rep
r se tatives of this County t er upon the above-mentioned
pro t for'nspe tion es. SEE REVERSE FOR EXPLANATORY LANGUAGE
SIG URE OF AP CA R AGENT DATE