HomeMy Public PortalAbout5311 ARDEN DR_Mechanical__ WCIRKE :S'CON4i�r NSA 1 10A, iJr_Ci ARATION CEA 86 8(2.80) Q P IP UC ATT O N FOR P E R MT
I hereby atfirC, that I have a' certificate of consent to self
,insure.'0'-a certificate of Workers'Compensation Insurance,or HIEATOfi�t,�_V ENTAL ATI[�'I�"y_AIR CONDU��®Ir�15(�lu CG
a certified`^4pv thPrepF(Sec.3800,Lau.C_),
Policy NoT� IlCompany COUNTY.OF LOS ANGELES BUI WING AND SAFETY
Certified copy is hereby fur ished.
=1 Certified copy is filed Frith he county wading i> p cti.^ ADDRESS
DL ESS i��— nr
&n_de^af•r ,n�", FQff$ APPLIC�tRiT T® IFILL OIII
Date 7ri0 t-�/Appiicaa:_ �_ _ (PRINT OR TYPE ONLY) ADDRESS
LOCALITY ��I/V10
CERTIFICATE OF EXENI '" ION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
COMPENSATIC INSURANCE NEAREST
CROSS ST. }
(This sectian need not inti cIr �ie:ed N the work involved ABSORPTION UNIT, BTU —_ a
by the permit is fo- CPC ht L_eCi db''k s ($Scat) or less.) t �f/p/ DISTRICT NO. PRS eSSED 3Y 0
I certify that in the performance of the.work for which this Ir I AIR HANDLING UNIT,CFMJ /—a/, _IV �D99V
permit is issued, I shall not employ any person in any manner ° _
so as to become subject to the Workers' Compensation Laws. �� BOILER•,BTU 0
APPROVALS DATE INSPECTOR'S SIGN - nE V
Date. Applicant li COMPRESSOR,BTU t�CJ�-� ROUGH a
NOTICE TO APPLICANT: if, after making this Certificate ofVENTILATION SYSTEM U)
Exemption, you shouA 'become subject to the Workers' FINAL /- "� Z
Compensation provisiors of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATI N
with comply with such provisions or tiiis permit shall be
deemed revoked.
FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR: BTU
I hereby affirm that I am licensed under provisions of Chapter HEATER: SUSPENDED UNIT
9 (commencing with Secti-3n 7000)of Division 3 of the Busi- WALL
ness and Professions Code, and my license is in full force and
effect. r�I
License Num`er�_ T,ic.Class V�
Contractor__�� Date_Td,1!
I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer L�Plan check fee 25%Of above.
acting in my professirnzl czpacity (Section 7051, Bus-
iness and Professions Code). PERMIT ISSUING FEE $
Lic.or Reg.No. Date TOTAL PEE
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from- the Contractor's NAME
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): I ADDRESS
® I, as owner of the property,'will do the work and the TEL. NO.
structure is not intended or offered for sale (Section CITY
7044, Business and Professions Code). �-
(OWNER --- _ — It
I, as owner of the properly, am exclusively contracting,,
with licensed contractors to construct the project I ADDRESS —_ � '� 015 9, A
(Section 7044, Business and Professions Code). �_—
CII TY TEL.NO.
CONSTRUCTLON LENDING AGENCY -- #'o 0 0 0 (G 1
1 hereby affirm that there is a construction lending agency CONTRACTOR
for the performance of the work for which this permit is _ _ 2 0 0 2 ]Q Q
issued(Sec..3097,Civ.C.). —_ -
Lender's Name I�—A—DDRESS Jerry M1 Y Y Y 0,0 0 2 7 Q Q U
Lender's Address_ — ' L
� CITY TEL.
NL✓4 NO. OS,O7-80
I certify that I have read this application and state that the 1 STATE LIC.
ab a information is correct.I agree to comply with all County LICENSE NO. _ CLSS C
ord nances and State laws regulating Hea Ing. Ventilating and
Air Conditioning, and he-e )y arc-i e r- presentatiees of this SEE REVERSE FOR EXPLANATORY LANGUAGE
Co mty to e itpr upon hr ou ,uned property for
Seact-n p
n
tee Date