HomeMy Public PortalAbout5328 ARDEN DR_Mechanical__ WORKER'S COMPENSATION a certificate
of consent to 76A346DPVJ9,69 APPLICATION FOR PERMIT LIME GREEN.
76A364C
I hereby ai7irm tftat 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.) �+ �j ,/
Policy No.!13�Company J s'67- lU�u'0 COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
Certified copy is hereby furnished.
Certified copy is filed with the county build' g ins p tion FOR APPLICANT TO FILL IN BDDRE33
department. Aw
(PRINT OR TYPE ONLY)
Date — Applicant / LOCALITY T1� e / T /�,T
NO. TYPE OF APPLIANCE OR EQUIPMENT. FEE _fi`''t L!i �✓f
/
CERTIFICATE EXEMPTION FROM WORKS' NEAREST
. CROSS ST. L( ve,
COMPENSATION
NSATION INSURANCE ABSORPTION UNIT,BTU
This section need not be completed if the work involved ASSESSOR
( b P Y the MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
- DISTRICT NO. P CES D BY
I certify that in the performance,of the work for which this permit
BOJLER,BTU
is issued, I shall not employ any person in any manner so as to
become subject to,the Workers'Compensatioh Laws.
f COMPRESSOR,BTU (J(Jv
_ APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of I IROUGH
Exemption,you should become subject to the Workers'Compensation' EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL 14r
provisions or this permit shall be deemed revoked. p FURNACE: FAU I GPLAVITY.
LICENSED CONTRACTORS DECLARATION ! FLOOR BTU VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT
(Commencinb with Section 7000) of Division 3 of the Business and HEATER: WALL
Professions Code,and my license is in full force and effect. IS
4 IFLicense Number Lio Class L� tl`
-J}w "'l }
IL
Contractor, Date " O
I am exempt under Sec: Plan Check fee - .jN;3 7 7 -.70 C-)
s�„r:;
B.&P.C.for this reason PERMIT ISSUING FEE$ 0 ;_ i=_E:. I OO
Date: TOTAL FEE JO ;':?u=tf,` i f` U
W
Signature d
OWNER-BUILDERDECLARATION PLAN CHECK APPLICANT co
4,f 15 }S t t ,= w/a Z
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.
structure is not intended or offered for sale (Section 7044,
Business and Professions Code). OWNER
0 I, as owner of the property, am exclusively contracting MAIL Ir E
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY TEL.NO. n
I herpeby affirm that there is a constructions lending agency for CONTRACTOR' t A AR
/
the erformance of the work for which this permit Is issued (J Nt V , t
(Sec. 3097,Civ.C.):
ADDRESS
Lender's Name `� �
7V TEL.NO. �J
12y/mCITY
Lender's Address STATE LIC.-' J /
I certify that l have read this application and state that the above LICENSE NO. CLASS C` IV
information is correct. I agree to comply with all County ordinances
and State laws elating t building construction,and hereby authorize
representativ s of this ounty,to enter upon the above-mentioned
property f inspect' of purpo SEE REVERSE FOR EXPLANATORY LANGUAGE
SIG7UR APPLICANT OR AG T DATE - '