HomeMy Public PortalAbout5128 ARDEN DR_Mechanical__ DECLARATI
W 1that I haveCOMPENSATION
ate of consent to 76A346DPW9169 APPLICATION FOR PERMIT LIME GREEN
76A364C
I hereby affirnr 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
f((S/e�c..y3800 Lab. C.) F>Dob!i L
P❑oliolicyNo.ft '-14113ZPompanyT� �'tY1�l Cl `
COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.:.
Certified copy is hereby furnished. /� `
❑ Certified copy is filed with then my buil ing inspection FOR APPLICANT TO FILL IN A-BUILDING �Z g /—tt'Gle►�l
de artment (PRINT OR TYPE ONLY)
Date Applic nt tiOCALITY�� }
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
NEAREST (�
CER FICATE OF EXE PTION FROM WORKERS' CROSS ST.L.oweNr
COMPENSATION INSURANCE ABSORPTION UNIT,BTU
This section need not be com leted if the work involved b ASSESSOR
( P Y the - MAP BOOK - �5. PAGE OI PARCELO/.6
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU
become subject to the Workers' Compensation Laws.
COMPRESSOR,BTU
APPROVALS DATE IN ECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT If, after making this Certificate of ROUGH
Exem'ptien,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith'comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU RAVITY r
LICENSEDCONTRACTORS-DECLARATION FLOOR BTU ,� 'VALIDATION
I hereby.affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT
(commencing with Section 7000) of Division 3 of.the Business and HEATER: WALL
Professions Code, and my license is in full'force and effect.
U
License Numb �n 2 Lic.Class 2
Contra for Date
29 t 3 a
❑ I am exempt under Sec. Plan check fee
BAP.C.for this reason PERMIT ISSUING FEE$ 0
Date: TOTAL FEE Q U
W
Signature IL
PLAN CHECK APPLICANT Z
OWNER-BUILDER DECLARATION
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
❑' I, as owner of the property, or my employees with wages _
as their sole compensation, will do the work and the CITY TEL.NO. _L i1.5 'tU
structure is not intended or offered for sale (Section 7044, _
Business and Professions Code). NER Va. SA t_6-A b d � t
❑ I, as owner of the property, am exclusively contracting MAIL CIT A 1 :13 40
with licensed contractors to construct the project (Sec- ADDRESS 57 12,0. Ay—CLC—V%_ �� _
tion 7044, Business and Professions Code). 'j'� S i IL(it JJ
CITYI� C` TEL.NO.Z�-5, 1-f(9 (
CONSTRUCTION LENDING AGENCY `` -` �� �• , -
I hereby affirm that thereCONTRACTOR ,/�
,is a construction lending agency for , t-` Il (�5
the performance of the work for which this permit Is issued 1 e (� '/ —��d L
(Sec.3097,Civ.C.). / TG I
ADDRESS-;t. �� I�InL01� l]� tsisj —l7jL3� _ ''7
Lender's Name (, �,g '= �'`
CITY)RA SOt�� TEL NO.1 l S ciU U {_?ct�!
Lender's Address ^ y0
I certify that I e ad this application and state that the above L CAENSE NO. -42�'SZ CLASS
info
correct. 1 agree to comply with all County ordinances
and St laws relatin to building construction,and hereby authorize
repr entatives oft s County to enter upon the above-mentioned
p perty for insp ction purposes. / r� SEE REVERSE FOR EXPLANATORY LANGUAGE
d �7�
NATURE OF APPLICANT OR AGENT DATE