HomeMy Public PortalAbout4845 ARDEN DR_Mechanical__ ION
CLARAT
' I h E.
WORKER'S I have
a certificate
of consent to 76A346DPW9/89 APPLICATION FOR PERMIT LI
I hereby affirm that.I have a certificate of consent to self insure, 76A364C GKEEN {�
or a certificate of Workers Compensation Insurance, or a certified HEATING-VENTILATING.-AIR CONDITIONING I I
copy thereof(Sec.3800 Lab.C.) u
Policy No IISC I�I C�S(�mpany COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
F-1 Certified copy is hereby furnished.
Certified Copy is filed with the county b ilding inspe tion FOR APPLICANT TO FILL IN BUILDING
Y
department: ' (PRINT OR TYPE ONLY)
Date , 1 lApplicant Sul NO. TYPE OF APPLIANCE OR EQUIPMENT - FEE LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
CROSS ST.
COMPENSATION INSURANCE, ABSORPTION UNIT,BTU
(This section need not be completed if the work involved by the MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as.to BOILER,BTU
become subject to the Workers'Compensation Laws. - Q Give�e -
COMPRESSOR,BTU U 49- C 0
APPROVALS DATE INSPECTOR'S SIGNATURE
Date - Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH _
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION. FLOOR BTUVALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
(commencing with Section 7000) of Division 3 of the Business and WALL
Professions Code,and my license is in full force and effect.
License Number ' " ° Lic.Class
CL
Contractor Date Z
❑ I am exempt under Sec. Plan Check fee O
BAP.C.for this reason PERMIT ISSUING FEE$ ` �D U
Date: TOTAL FEE p D a
Signature (n
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT _
Z
I hereby affirm that 1 am exempt from the Contractor's License Law NAME '
for the following reason (Section 7031.5, Business and Professions
Code): ADDRESS _
I, as owner of the property, or my employees with wages _
as their sole compensation, will do the work and the CITY TEL.NO. _
p _a. 1. --
structure is not intended br'offered for sale (Section 7044,
Business and Professions Code). OWNER ,LA-a- �J .L[F-1 r!=
❑ I, as owner of the property, am exclusively contracting MAIL nn z i * F
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code).
' CONSTRUCTION LENDING AGENCY CITY 'O 12- TEL.NO.
'the
affirm that there is a construction lending agency for n A ' -F IH
the performance of the work for which this permit Is issued CONTRACTOR �V `i� Y�
(Sec.3097, Civ.C.).
ADDRESS S Q�f. A�v Q -
Lender's Name -'- '° _; J.
CITY ( I TEL.NO. lJ Q�i g' -� - };w i";n
Lender's Address C�� 4 Ail
LIC. S
STATE
I certify that I have read this application and state that the above LICENSE NO. Gj CLASS
information is cogect. I agree to comply with all County ordinances
and State la relating to building construction,and hereby authorize
representati sof this County to enter upon the above-mentioned
prope fol inspection p rpos SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNA OF APPLI ENT DATE ,