HomeMy Public PortalAbout5212 ARDEN DR_Mechanical__ WORKER'S COMPENSATION
certificate
of consent to 76A346DPW9,69 APPLICATION FOR PERMIT LIME GREEN
76A364C
1 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.),•
❑
cy No. Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS ' BUILDING AND SAFETY DIV.
Certified copy is hereby furnished.
❑ Certified coy is filed with the county buildin g Insp ADDRESS
ection FOR APPLICANT TO FILL IN BUILDING
depa ment. (PRINT OR TYPE ONLY)
Date 9 Applicant LOCALITY G
.. NO. TYPE OF APPLIANCE OR EQUIPMENT FEE.
CER FICATE OF EXEMPTION FROM WORKERS' NEAREST
CROSS ST.
COMPENSATION INSURANCE ABSORPTION UNIT,BTU
This section need not be com leted if the work involved b the ASSESSOR
( P y MAP BOOK ,PAGE PARCEL
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM -
DISTRICT NO. PROCESSED BY
I cissued, It in ll note employ
nan of the work for which this permit
is issued; I shall not employ any person in any manner so as to BOILER,BTU .f'D p
become subject to the Workers'Compensation Laws. d O
COMPRESSOR,BTU
APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers' Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked: FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT—
(commencing
NIT(commencing with Section 7000) of Division 3 of the Business and HEATER: WALL 4o
Professions Code, and my license is in full force and effect.
License Number Lic.Class
CL
Contractor Date OU
❑
I Plan check fee am exempt under Sec. "Q
BAP.C.for this reason PERMIT ISSUING FEE$ 0
U
Date: TOTAL FEE d
Signature (n
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
1 hereby affirm that I am exempt from the Contractor's License Law NAME
for the following reason (Section 7031'.5, Business and Professions s JL
ADDRESS ACC e'P
I, as owner of the property, or my employees with wages 3307 4800
as their sole compensation, will do the work and the CITY TEL.N0.
structure is not intended or offered'for sale (Section 7044, 1 D'EN'S
Business and Professions Code). NER
❑
t
1, as owner of the property, am exclusively contracting MAIL i O s AL 48 .00�(
with licensed contractors to construct the project (Sec- ADDRESS fZ t 3 CHUCK 4V oLiU
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY ' C� `TEL.NO. t NAf��sE v 00
I hereby affirm that there is a construction lending agency for CONTRACTOR ilii J
the performance of the work for which this permit Is issued �r�it4
(Sec.3097,Civ.C.). y
ADDRESS. I� 13 -IJLsL1 1! 3/9
Lender's Name
CITY TEL.NO. 7510 1 AM 8:55
Lender's,Address STATE LIC.
I certify that I have read this application and state that the above LICENSE NO. CLASS
information is correct. I agree to comply with all County ordinances
MEOFAI
g to u' ing construction,and hereby authorize
Is un t nter pon the above-me 'oned
io p s. SEE REVERSE FOR EXPLANATORY LANGUAGE
AGENT E