HomeMy Public PortalAbout9823 HOWLAND DR_Mechanical__ WORKER'Shave 36
COMPENSATION 26W46 W9/B9 APPLICATION FOR PERMIT LIME GREEN
]O ,tC
I hereby affirm that I have a certificate of consent to self insure, (�
or a redificate of Worker's Compensation Insurance, or a certified HEATING- VENTILATING- AIR CONDITIONING I I
copy thereof(Sec.3800 Lab. C.) LI
Policy No. Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
Certified copy is hereby furnished.
Certified copy is tiled with the county building inspection . FOR APPLICANT TO FILL IN BUILDADDRESS
departme t. (PRINT OR TYPE ONLY)
^7
Dat aY J ��A i LOCALITY G
pplice NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS
ABSORPTION UNIT.BTU I 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
nISTPILi 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 D �0O ie
become subject to the Workers'Compensation Laws. _
COMPRESSOR,BTU
APPROVALS DATE INSPECTOR'S SIGNAi NE
Data Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH 1 Lr
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 G VI DO
LICENSED CONTRACTORS DECLARATION FLOOR BTU L!� D VALIDATION
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 Numbd��"" `9Lic.Class Cz a 3 p�
ractol' """" DatO ' � V
❑ I am exempt under Be . Plan Check fee -
B.BP.C.for this reason PERMIT ISSUING FEE S 0
Date: TOTAL FEE W
a
Signature
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT co)
I hereby affirm that I am exempt from the Contractor's License Law NAME Poo.for the following reason (Section 7031.5, Business and Professions
Code):❑ ADDRESS ACCT a.•
I, as owner of the property, or_my employees with wages
as their sole compensation, will do the work and the JSO� 1821.&,_1
p CITY TEL.NO.
structure is not intended or offered for sale (Section 7044, 1 TTENS
Business and Professions Code). OWNER _
❑ I, as owner of the property, am exclusively contracting MAIL TOTAL 182 _ 376
with licensed contractors to construct the project (Sec- ADDRESS (�
tion 7044, Business and Professions Code). TEL.N�7 �� ffj7 CHECK 182.6-6
CONSTRUCTION LENDING AGENCY GG CHANGE Oct.
hereby affirm that there is a construction lending agency for CONTgACTO , -
the performance of the work for which this permit Is issued G
(Sec.3097, Civ.C.). /
ADDRESS T' I{Ijl'Ir_13001 11/ 452
Lender's Name CITY 4 y TEI���`�rO �f f3I2J6 VV 1 AM 4:41
Lender's Address / 9
I certify that I have read this application and state that the above LICENSE NO 76 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
Jt for
spa oFi pu SOS. //'�- Y2_ SEE REVERSE FOR EXPLANATORY LANGUAGE x
A flE OF APPLICANT OR AGENT GATE