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HomeMy Public PortalAbout4849 ARDEN DR_Mechanical__ ION WORKER'S I have a certificate of consent to 76A346DPW9,69 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: `]9620 6company STATE' 'IAD COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV. C Ified copy is hereby furnished. Certified copy is filed with the county building in tion FOR APPLICANT TO FILL IN BUILDING SS S department. `Z ` (PRINT OR TYPE ONLY) �\ LOCALITY /�1 i Date Z—Z'. Applica NO. TYPE OF APPLIANCE OR EQUIPMENT FEE ��Vf AC CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST / L COMPENSATION INSURANCE CROSS ST. Z-o ABSORPTION UNIT,BTU ASSESSOR (This section'need not.be completed if the work involved by the MAP BOOK PAGE PARCEL permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO, PROCESSED BY I certify that.in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to BOILER,BTU become subject to the Workers'Compensation Laws. �;� / f COMPRESSOR,BTU (D 1 APPROVALS DATE INSPECTOR'S SIGNATURE Date Applicant VENTILATION SYSTEM NOTICE TO APPLICANT: If, after making this Certificate of ROUGH " Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER provisions of the Labor Code, you must forthwith comply with such FINAL provisions or this permit shall be deemed revoked. I FURNACE: FAUG TY LICENSED CONTRACTORS DECLARATION / FLOOR BTU I M 24, VALIDATION I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT (commencing with Section 7000) of Division 3 of the Business and WALL Professions Code,and my license is in full force and effect. r '¢�j 4 8� �- Zy / 5 IJU iL .- yiE.'•`I s 3' License Number Lic.Class Contractor OS&446 (Tf►NIML Date Z'-2— 0 ❑ I am exempt under Sec. Plan Check fee U B.&P.C.for this reason PERMIT ISSUING FEE$ 0 tt,i i 3t a = 0 Date: TOTAL FEEIld ; 1ttj 3I a I'a W Signature (- PLAN CHECK APPLICANT - W OWNER-BUILDER DECLARATION _ , ._: Z hereby affirm that I am exempt from the Contractor's License Law NAME // L E ooo_(I, 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 CITYj� TEL.NO.� Q� structure is not intended or offered for sale (Section 7044, �v Business and Professions Code). OWNER F71 I, as owner of the property, am exclusively contracting MAIL � 7 J/ with licensed contractors to construct the project (Sec- ADDRESS V R N s©2 tion 7044,Business and Professions Code). / CONSTRUCTION LENDING AGENCY CITY `N� ��� TEL.NO. I hereby affirm that there is a construction lending agency for CONTRACTOR �l�� A /)yC� , the performance of the work for which this permit Is issued N C/In C.. cr (Sec.3097,Civ.C.). ADDRESS 674- M// A s i , 6—fLender's Name /i / / G L CITY C- `N TEL.NO.gL04<,91-ZZ Lender's Address STATE LIC. v ' - I certify that I have read this application and state that the above LICENSE NO. 1 CLASS e-zz) 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 ins n purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE S NATURE OF APPLICANT OFT-AGE DATE