HomeMy Public PortalAbout5004 ARDEN DR_Mechanical__ WORKER'S COMPENSATION DECLARATION 20-0046 DPW 9/89 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.) L -
Policy No.1V� 2-b Company s �t..tn�i COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV..
❑-,/ Certified copy is hereby furnished.
Ll� Certified copy is filed with the county build' inspection FOR APPLICANT TO FILL IN ADDRESS
department. (PRINT OR TYPE ONLY)
LOCALITY
Date !j3 Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM ORKERS' NEAREST Y /
CROSS ST.
COMPENSATION INSURANCE O
ABSORPTION UNIT,BTU ASSESSOR
(This section need not be completed if the work involved by the MAP BOOK PAGE PARCEL:46
permit is for one hundred dollars($100)or less.) - AIR HANDLING UNIT,CFM DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU
become subject to the Workers' Compensation Laws.
COMPRESSOR,BTU
APPROVALS DATE INSPE TOR'S SIGNAT RE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
(commencing with Section 7000) of Division 3 of the Business and WALL
Professions Code,and my license is in full force and effect.
�ti 5 i Q�iLL A a
License Number -49(00177 Lic.Class „�t_i og
l�Iiw'
�tatib scoT C-Z3 _q3 , j i ITEiM : ao
Contractor C1^a Date
❑ I am exempt under Sec. Plan check fee "KITHL 33 = 45 U
B.&P.C.for this reason PERMIT ISSUING FEE$ -H ;K 3.45 O
Date TOTAL FEE3 '-:H fN1 °`'{= W
Signature 0-
PLAN CHECK APPLICANT
OWNER-BUILD LARATION _
I hereby affirm that I am exempt from a Contractor's License Law NAME . , -I- f
for the following reason (Section 7031.5, Business and Professions 1'le. b Sc.Q �� '
Code): ADDRESS r { /}.,}.a •HI f s i�:
❑ I, as owner of the property, or my employees with wages 7 56 1. �L-
as their sole compensation, will do the work and the CITY ,��. I-Q �. TEL.NO. 5 2'7/
structure is not intended or offered for sale (Section 7044,
Business and Professions Code). OWNER `y� ✓1 v;
❑ I, as owner of the property, am exclusively contracting MAIL �J
with licensed contractors to construct the project (Sec- ADDRESS 50p %gv1J A.._
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY �e.L^, •� TEL.NO. Sb
Ihereby affirm that there is a construction lending agency for CONTRACTOR . ,
the performance of the work for which this permit Is issued r-'L SICO�f�t�
(Sec.3097,Civ. C.).
ADDRESS 45S5`6 k L �..���� �✓
Lender's Name
CITY r ' ltiti . TEL.NO. 571 3 2 7/
Lender's Address STATE LIC. 1 6
certify that I have read this application and state that the above LICENSE NO. S CLASS
information is correct. I agree to comply with all County ordinances
and State laws relating to building construction,and hereby authorize
representatives of t 's County to enter upon the above-mentioned
property for inspe n purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
�--=- fo- -q 3
SIGNATURE OF APPMAIT 017AG NT DATE '�
7ea3e4 — cEeie — 3-69 APPLICATION FOR PERMT
HEATING - VENTILATING - AIR CONDITIONING
COUNTY OF LOS ANGELES BUILDING c��rQ� Al DEPARTMENT OF COUNTY ENGINEER ADDRESS �`Y
BUILDING AND SAFETY DIVISION
JOHN A. LAMBIE, COUNTY ENGINEER LOCALITY "�/p�E" C'�Tf
COLEMAN W.JENKINS,SUPERINTENDENT OF BUILDING NEAREST
CROSS ST. O /7
FOR APPLICANT TO FILL IN OWNER
(PRINT OR TYPE ONLY) %� /�
MAIL
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE ADDRESS
,,��c�o0 �o/L7-
ABSORPTION SYSTEM, BTU CITY /G/�/ Z� j7-,WE L. NO.4Z�¢7&403
AIR HANDLING UNIT, CFM CONTRACTOR
ADDRESS
BOILER, HORSEPOWER
CITY TEL. NO.
COMPRESSOR, HORSEPOWER STATE LIC.
LICENSE NO. CLASS
VENTILATION SYSTEM DISTRICT NO. GROUP ZONE PROC SED BY
EVAPORATIVE COOLER O
/ FURNACE: FAU GRAVITY
FLOOR BTU �ZCS,O� 0 INSPECTION RECORD
HEATER: SUSPENDED UNIT
WALL >-
CL
0
V
0
H
V
U-1
CL
U)
NEW-ADDITION- PERMIT $ 3 00 Z
ALTER_REPAIR_ TOTAL FEE $
PLAN CHECK APPLICANT
NAME
ADDRESS
CITY TEL. NO.
IHEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY /
WITH ALL ORDINANCES AND LAWS REGULATING HEATING,VENTI- APPROVALS DATE NSPEC 'S SIGNATURE
LATING, AIR CONDITIONING.
IHEREBY CERTIFY THAT I AM NOT ACTING IN VIOLATION OF ROUGH
CHAPTER 9, DIVISION 3, OF THE BUSINESS AND PROFESSIONAL FINAL
CODE OF THE STAT OF CALIF p RNIA
SIGNATURE Lp �7NJACK R. ALLEN, S PERVISINGMECHANIC NG'R.
OF PERMITTEE
PERMIT VALIDATI CK. M.O. CASH
PLAN CHECK VALIDATION
ULo 9 6 3"9-� Ei4U D 8.0 0cv
SEE BACK OF APPLICATION FOR COMPLETE FEE SCHEDULE