HomeMy Public PortalAbout4851 ARDEN DR_Mechanical__ 16N
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. 7_eF6 Company STAB�LIAI17 COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
C led copy is hereby furnished.
Certified'Copy is filed with the county buil ing inspecti n FOR APPLICANT TO FILL IN gDDRES
department. (PRINT OR TYPE ONLY) [
ZIA
Date sZ.�Applican. NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY
ladar
NEARESTn��
CERTIFICATE OF EXEMPTION FROM WORKERS' 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($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU
become subject to the Workers'Compensation Laws. ! 3/
COMPRESSOR,BTU �Oi
APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM A
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH lK]i
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAUGRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU 3 7_57 VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
(commencing with Section 7000) of Division 3 of the Business and WALL—
'Professions
ALL'Professions Code,and my license is in full force and effect. I
License Number Lic.Class 0_ • ✓ , -
Contractor /� n,l/lt"at�Date • , ,.l, V
❑ I am exempt under Sec.' Plan Check fee ACC i °'e'
B.&P.C.for this reason PERMIT ISSUING FEE$ =` °"I O
Date: TOTAL FEE LIO }TP W
15
SignatureTOTa-
PLAN CHECK APPLICANT
OWNER-BUILDER DECLARATIONi.Fj 1.:. 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 8'7 <:-i
EJ I, as owner of the property, or my employees with wages
as their sole compensation, will do the work and.the CITY I /� TEL.NO. Q/: ;(!)'sly—« `_a%` it
structure is not intended or offered for sale (Section 7044, l•�M c�tv
Business and Professions Code). OWNER
❑ I, as owner of the property, am exclusively contracting MAIL SCE
with licensed contractors to construct the project (Sec- ADDRESS.
tion 7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY TEL.NO.
I hereby affirm that there is a construction lending agency' for CONTRACTOR ,
the performance of the work for which this ermit Is issued
(Sec.3097,Civ.C.). _
ADDRESS
Lender's Name
CITY k_ 7/1�� TEL.NO. JZZ
Lender's Address STATE �+ w� LIC.
I certify that I have read this application and state that the above LICENSE NO. CLASS 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
pro rty�11j;Nl
n purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
SI NATURER IT4 DATE