HomeMy Public PortalAbout9218 LIVE OAK AVE_Mechanical__ ION
DECLARAT
W0Jhat IS have
aceSATate of consent to 76A346DPW9,B9 APPLICATION FOR PERMIT LIME GREEN
76A364C
I hereby affirm That I have a certificate of consent to self insure, n
or a certificate of Worker's Compensatio Insu nce, or a certified HEATING -VENTILATING-AIR CONDITIONING
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copy thereof(Sec.3800 Lab.C.) , (&'e P
Policy No.I�`lf2 Company S COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
❑ Certified copy is hereby furnished.
APPLICANT TO FILL IN BUILDING
Certified copy is filed with the county building inspection FOR PRINT OR TYPE ONLY ADDRESS
department. ( )
Date LI`—L ApplicantLOCALITY
N0. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM W RS' NEAREST.
CROSS ST.
COMPENSATION INSURANCE ABSORPTION UNIT,BTU
This section need not be completed if the work involved b the ASSESSOR
( P y MAP BOOK 0�+ PAGE V/ PARCELBp
47
permit is for one hundred dollars($100)or less.) IR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU 4-,-P
become subject to the Workers'Compensation Laws.
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COMPRESSOR,BTU �t/OOO
APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM /'
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH 2%
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATIONd
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
(commencing with Section 7000) of Division 3 of the Business and WALL
Professions Code,and my license is in full force and effect. /
License Number��d v Lic.Class _L0 ` p�-yam
— ' CL
C77 CL
/Corifracfor Date t —6 j V
❑ Pian check fee
i �i oa
I am exempt under .S c.
B.&P.C.for this reason PERMIT ISSUING FEE$ loS ''I�iU 0
Date: TOTAL FEE 1 1 tT.l'MS W
Signature PLAN CHECK APPLICANT AL 22 m 25� Z
OWNER-BUILDER DECLARATION {1-: .Lt
I hereby affirm that I am exempt from the Contractor's License Law NAME pop �•�EEK `"```
for the following reason (Section 7031.5, Business and Professions ;;H(I)NGE �13II
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. j
structure is not intended or offered for sale (Section 7044, / 0000-0001 6! 1Uf 91_3
Business and Professions Code). 16WNER 13 �� o
❑ S7
I, as owner of the property; am exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY TEL.NO.
/ G� G!T
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 �� Y TEL.NO. O , . —C
Lender's Address STATE // �t^ LIC. O
I certify that I have read this application and state that the above LICENSE NO. tl iG } CLASS 61 e7, el-
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
property fo�PLI.eAfiOOFVtENT
�ses. SEE REVERSE FOR EXPLANATORY LANGUAGE
�IGNl�IHR F DATE