HomeMy Public PortalAbout4855 ARDSLEY DR_Mechanical__ WORKER'S I have
a ceSATION Df consent
to 76A346DPW 9/89 APPLICATION POR PERMIT L� E GREEN:
76A364C
I✓;ereby af>}irm 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.)
Policy No.lZLS5fr f(-yZrnpany .)GW 07" COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
Certified copy is hereby furnished.
E
0- Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN BUILDING
ADDRESS G t
department. (PRINT OR TYPE ONLY) Y 17
`=—r —f NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY
Date Applicant
7
1
EAREST
N -C (v
CERTIFICATE OF EXEMPTION FAM WORKERS' CROSS ST. /
COMPENSATION INSURANCE ABSORPTION UNIT,BTU
(This section need not be completed if the work involved by the ASSESSOR
MAP permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
DISTRICTNO. PROCESSED BY
PAGE PARCEL
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU
become subject to the Workers'Compensation Laws. (�
COMPRESSOR,BTU
APPROVALS DATE INSPECTOR'S SIGNATURE '
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code,.you must forthwith comply with such FINAL Jyl
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY 41
LICENSED CONTRACTORS DECLARATION FLOOR BTU V VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDEDUNIT
(commencing with Section 7000) of Division 3 of the Business and HEATER: WALL
Professions Code,and my license is in full force and effect.
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License Number I y Lia Class C 2�L
Contractor Date a �'_1!
Plan check fee OU
am exe t and Sec. t
P I �.._
B.&P.C.for this reason PERMIT ISSUING FEE$ ' +.•-s R- JL.
ss
Date: TOTAL FEE �'/ I,~ U
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Signature �'1 j�'����' -'. ='`� a
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
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): ADDRESSEJ
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 "Rem
I, as owner of the property, am exclusively contracting MAIL X
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY TEL.NO.
I hereby affirm that there is a construction lending agency for CONTRACTOR
the performance of the work for which this permit Is issued �.
(Sec. 3097, Civ. C.).
ADDRESS
Lender's Name
CITY TEL.NO. O
Lender's Address STATE n LIC.
I certify that I have read this application and state that the above LICENSE NO. / 7 CLASS G 2
information is correct. I agree to comply with all County ordinances
and State laws relating to building construction,and hereby authorize
representatives of this County to enter upon the above-mentioned
proper y for inspec pur oses. SEE REVERSE FOR EXPLANATORY LANGUAGE
NA O AP ANT R GENT DATE