HomeMy Public PortalAbout9230 LIVE OAK AVE_Mechanical__ ION
that I have
aceSATate of consent to 76A346DPW9,69 APPLICATION FOR PERMIT LIME GREEN
� 76A364C
I heisby di"'f'nithat I have a certificate of consent to self insure,
or a certificate of Worker's Compensation Insurance, or a certified HEATING -VE TILAXING-AIR CONDITIONING
copy thereof
A(Se�c.` �M4 3880.00 Lab. C.) ll
Policy t 4)9401 company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
El Certified copy is hereby furnished.
BUILDCertified copy is filed with th7�&
FOR APPLICANT TO FILL IN ADDRVOdepartur (PRINT OR TYPE ONLY) ADDRESDate ApplicanNO. TYPE OF APPLIANCE OR EQUIPMENTNEAREST
FEE LOCALITY ^
CERTIFICATE OF EX PTI FROM WORKERS' CROSS ST.
COMPEN TIO NSURANCE ABSORPTION UNIT,BTU
ASSESSOR
(This section need not be .ted if the work involved by the MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU /t G
become subject to the Workers'Compensation Laws. !/A
COMPRESSOR,BTU
APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU GR_UITY VALIDATION
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
(commencing with Section 7000) of Division 3 of the Business and W L
Professions Code,and my license is in full force and effect.
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License Number Lic.Class Rt• •f'g �p __
IL
Contra a3 �SF' J j_ ITrMq o
❑ .. � �
m exempt under Sec. Plan check fee
TO
-s `5 =
EE$ tc•
B.&P.C.for this reason PERMIT ISSUING F � t''f'•�` '��i "'a: V
-i�
Date: TOTAL FEE � '•:_HAINE p i 4i i 0.
Signature (n
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
1 hereby affirm that I am exempt from the Contractor's License Law NAME
for the following reason (Section 7031.5, Business and Professions iI_
Code): ADDRESStill€�`°•'-
❑ 1, as owner of the property, or my employees with wages
as their sale 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 JJq
❑ I, as owner of the property, am exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRESS 41Z 16
tion 7044, Business and Professions Code).
CITY TEL.NO.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for CONTR CT
the performance of the work for which this permit Is issued c�
(Sec.3097, Civ. C.j. ,
ADDRES44 �]
Lender's Name r� ww
S TEL.NO.' 2!_7�Gf
Lender's Address STATE LIC. �w✓r4� !!!!
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
esentat' o his ounty toe ter upon the above-fnentioned
rop In ecti n po SEE REVERSE FOR EXPLANATORY LANGUAGE
URE OF APPLICANT OR AGENT ��TE
p.