HomeMy Public PortalAbout10684 ARROWOOD ST_Mechanical_4/10/1991_additional duct work for room DECLARAT
WORKER'S have
a certificate
of consent to 76A346DPW9/89 APPLICATION FOR PERMIT LIME GREEN
I+hereby affirm that_I have a certificate of consent to self insure, 76A364C
qr a cehific`ate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING
copy-thereof(6iiif,,.3800 Lab.C.)
Policy No. Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
❑ ' Certified copy is hereby furnished.
❑ Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN BUILDING
department. (PRINT OR TYPE ONLY) ADDRESS 106,94 Arrew"_,_
Date Applicant - LOCALITY f
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST ST 11
COMPENSATION INSURANCE CROSS
ABSORPTION UNIT,BTU ASSESSOR
(This section need not be completed if the work involved by the MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU
become subject to the Workers'Compensation Laws.
COMPRESSOR,BTU `l
,� APPROVALS \/ DATE INSPECTOR'S SIGNATURE
Date 4 Applicant f•�leh VENTILATION SYSTEM ,V
NOTI E TO PPLI ANT: If, after making this Certific!/te of ROUGH l 7���� �.y�Zc✓�
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER I
provisions of the Labor Code, you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTULIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED - UNIT
(commencing with Section 7000) of Division 3 of the Business and WALL
Professions Code,and my license is in full force and effect.
License Number Lic.Class
CL
Contractor Date �(�/Jv / , V
[71 Plan check fee
I am exempt under Sec. CC
B.&P.C.for this reason PERMIT ISSUING FEE$ 1-0 O
U
Date: TOTAL FEES 0 W
Signature (n
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT f Z
I hereby affirm that I am exempt from the Contractor's License Law NAME /) oil.for the following reason (Section 7031.5, Business and Professions [[[
e): ADDRESS
I, as owner of the property, or my employees with wages
as their sole compensation, will do the work and the CITY -te. g e' CTEL'.
-_
Business and Professions Code). OWNER Sew'/1 A,` I + t +
❑ 1, as owner of the property, am exclusively contracting MAIL F0 1 AL 25 . 00
with licensed contractors to construct the project (Sec- ADDRESS +_
tion 7044, Business and Professions Code). CITY TEL.NO. t.}-}E,'K' _E e LM
)
�!i u�
CONSTRUCTION LENDING AGENCY �-Li„ !"14 k2t n j{(
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
Iiy,4r `.IJ 3+!
Lender's Name
CITY TEL.NO. _ =1 .'I n, •'
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
and State laws relating to building construction,and hereby authorize
representatives of this County to enter upon the above-mentioned
pro erty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
AI I
-r Lam/
SIGNATURE OF APPLICANT OR AGENT ATE