HomeMy Public PortalAbout5117 ARDEN DR_Mechanical__ A
WORKER'S COMPENSATION
certificate
of consent to 76A346DPW ;69 APPLICATION. FOR PERMIT LIME GREEN
76A364C
I hereby aff"i'rm'that I have a certificate of consent to self insure,
or a certificate of Vorker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING
copy thereof(Sec.3800 Lab. C.)
Policy No. Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
Certified copy is hereby furnished.
❑ Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN ADDRESS
department. (PRINT OR TYPE ONLY)
Date Applicant LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
P try-
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST n
COMPENSATION INSURANCE CROSS ST. YT
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($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manne o as to BOILER,BTU
become subject to the Work ompen on Lbws.
' n/ COMPRESSOR,BTU 2 APPROVALS DAT INSPECTOR'S SIGNATURE
Date G pplicant VENTILATION SYSTEM
NO ICE TO APPLICAN If, aft r making Is C//.ficate of ROUGH
Exemption,you should bec a sub' ct to the Workers' ompensation EVAPORATIVE COOLER
provisions of the Labor Cod must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY ZS �^ VALIDATION
LICENSED CONTRACTORS DECLARATION FLOOR BTU �[J
hereby affirm that I am licensed under.provisions of Chapter 9 HEATER: SUSPENDED UNIT
(commencing with Section 7000) of Division 3 of the Business and WALL
Professions Code,and my license is in full force and effect.
License Numbe � Lia Class
CL
Contractor lade Date f ' O
❑ I am exempt under Sec. Plan Check fee M:
BAP.C.for this reason PERMIT ISSUING FEE$ I^: i_- _0
Date:
U
TOTAL FEEWa
Signature IL
PLAN CHECK APPLICANT -'-i";- act,
OWNER-BUILDER DECLARATION t`-'I AL _.Z_
I herebyaffirm that I am exempt from the Contractor's License Law , ;y ff_"'"
P NAME s,f:; ii.
for the following reason (Section 7031.5, Business and Professions .—
Code): ADDRESS '.:lel"1•t16,
❑ I, as owner of the property, or my employees with wages -
as their sole compensation, will do the work and the CITY TEL.NO.
structure is not intended or offered for sale (Section 7044;
Business and Professions Code). OWNER ` C'1/W '- _:
❑ 1, as owner of the property, am exclusively contractingJt
jj-ir
MAIL
with licensed contractors to construct the project (Sec- ADDRESS l
tion 7044, Business and Professions Code). AF-12�
CONSTRUCTION LENDING AGENCY CITY ^ EL.NO.
I hereby affirm that there is a construction lending agency for CONTRALTO I"y
the performance of the work for which this permit Is issued
(Sec.3097,Civ. C.). V �
ADDRESS �a—
Lender's Name 3
CITY 0 TEL.NO
i
Lender's Address STAT LIC. ?
I certify that I have read this application and state that the above LICENSE NO. CLASS �� ✓�
i is correct. I agree to c ly with all County ordinances
and State law at ng to buildin on truction,and hereby authorize
representatives o is Count an r upon the abov -men'oned
property for' s on ur os . SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATOR F APPLICANT O NT DATE