HomeMy Public PortalAbout4847 ARDEN DR_Mechanical__ ION
DECLARAT
WORKER'S I have
a certificate
of consent to 76A346DPW9189 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. 1q�zo16 Company 6LAIr PUALP COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
❑
��Zrtified
tlfied copy is hereby furnished.
BUILDING
copy is filed with the cD bu inspec` n FOR APPLICANT TO FILL IN ADDRESS 4 ¢'
department. (PRINT OR TYPE ONLY)
-
Date ' Z' Applica 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 ASSESSOR
( b P Y the MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU �� _'
become subject to the Workers'Compensation Laws.
' COMPRESSOR,BTU G '•
APPROVALS DATE INSP TOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM /
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL S _
provisions or this permit shall be deemed revoked. FURNACE: FAU G V TY
LICENSED CONTRACTORS DECLARATION FLOOR BTU 4<1 VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
(commencing with Section 7000) of Division 3 of the Business and WALL
Professions Code,and my license is in full force and effect.
Olin
6 Q /1 ,^,�
�fw5
13(0
License Number T l� ¢ Lic.Classes }
Contractor ate
❑ I am exempt under Sec. Plan Check fee _`'_• t,
B.BP.C.for this reason PERMIT ISSUING FEE$ a I`I'
Date: T I_i�'4l 1'cB".. a#= _:L5 (j
TOTAL FEE
Signature •_•rl_+i 314 a .1 U)
PLAN CHECK APPLICANT
OWNER-BUILDER DECLARATIONF Via+�t;�, it e
I hereby affirm that I am exempt from the Contractor's License Law NAME x��c ' Hl Zr_
.L 3+
for the following reason (Section 7031.5, Business and Professions W u C16c�
Code): ADDRESS /f ',�/
❑ I, as owner of the property, or my employees with wages L�t_�ry S 6 " +Vt— 00,0 i–•`l010*1
as their sole compensation, will do the work and the CITY / TEL.NO. Cfa W M ii
structure is not intended or offered for sale (Section 7044, V S '+t'`++'' sll�l +�•"tv
Business and Professions Code). OWNER /
❑ I, as owner of the property, am exclusively contracting AIL
M /V /;�
with licensed contractors to construct the project (Sec- ADDRESS 3Z L `�.J42
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY TEL.NO.
I hereby affirm that there is a construction lending agency for CONTRACTOR pop
performance of the work for which this permit Is issued
(Sec. 3097,Civ.C.).
ADDRESS
Lender's Name V
CITY /11 TEL.40-707
Lender's`Address STATE VV LIC.
I certify that I have read this application and state that the above LICENSE NO. 7 $ CLASS v
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 in(s/p7 tion purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
SINATURE OF APPLI
CANT O EATS DATE