HomeMy Public PortalAbout8827-29-31 LAS TUNAS DR_Mechanical__ 20�6
• WORKER'S COMPENSATION a certificate
Of Consent to 76X364 DPW 9189 APPLICATION FOR PERMIT UME GREEN
• 76A3fi4C.
I hereby,affirm that I have a certificate of consent 10 self insure,
or a certificate of Worker's Compensation Insurance, or a certified - HEATING-VENTILATING-AIR CONDITIONING -
copy thereof{Qec.3800 Lab.C.)
Policy No: Company 4 I�Te-�&N b • COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
❑ .Certified copy is hereby furnished.
Certified co is filed with the courit building inspection FOR APPLICANT TO FILL IN BUILDING
PY Y 9 .•'��
apart - (PRIM ADDRESS OR TYPE ONLY) Y
Date LOCALITY�pplica NO. TYPE OF APPLIANCE OR EQUIPMENT FEE T � �� -
CERTIFICATE OF EXE. TI FROM WORKERS' NEAREST y I -
COMPENSATI SURANCE CROSS ST. �-
ABSORPTION UNIT,BTU ASSESSOR-
(This section need not be comple eddf 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 certifythat in the performance o/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 lhe�Workers'Compensation Laws,
COMPRESSOR,BTU
• _ APPPDVALs DATE INSPECTCH'SSICNATNRE
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 Cotle, you must forthwith comply with such FINAL `-
provisions or this permit shall be deemed revoked. FURNACE: FAU_GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU _ VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT_
(commencing with Section 7000) of Division 3 of the Business and HEATER: WALL
Professions Code;and my license is in full force and effect
N
License umber-, .S Z Lia Class, Go G 1z CAD Y--
�
(L
ContracFaxempt
Date O
❑ under sec. Plan checkfee U
Qr this reason PERMIT ISSUING FEE $ �/3 pp
Date: TOTAL FEE / pC d
Signature
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT U)Z
I hereby affirm that I am exempt from the Contractor's License Law NAME (
for the fallowing reason (Section 7031.5, Business and Professions ADDRESS -
Code): V Ae, 12� v
❑ I, as owner of the property, or my employees with wages ACCT.AT
as their sole compensation, will do the work and the CITY _ TEL.
structure is not intended or offered for sale (Section 7044, 35,1107 19•t�l
Business and Professions Code). OWNER i ITEMS
Elas owner of the grope Ny, am exclusively contracting MAIL r'1 i e--��x
• with licensed contractors to construct.the project (Sec- ADDRESS TOTAL19 ® OV
flan 7044, Business and Professions Code). CITU TEL NO. tHEt t
19.1 IIJ
CONSTRUCTION LENDING AGENCY �p
I hereby affirm that there is a construction lending agency for CONTRACTOR .1 G , CHANGE •[QI
the performance of the work for which this permit Is issued �ry �.
(Sec.3097,Civ.C.).- '
ADORES FJ W` ( _
Lender's Name �_�
CITY a�
Lender's Address - STATE LIG - • - 4"1i 111 1:01
I certify that I have read this application and state that the above LICENSE NO. L CLASS
information is correct. I agree to comply with all County ordinances
antl State laws relating to building construction,and hereby authorize .7
representatives tis County to er on t above-mentioned
property r lion pu rpos r ?/ SEE REVERSE FOR EXPLANATORY LANGUAGE.
i
9GNA E O PPQCANT OR AGENT DATE