HomeMy Public PortalAbout9546 LAS TUNAS DR_Mechanical__ ION
DECLARATI
WORKER'S ve a ceSATate of consent to 20-0046 DPW 9/89 APPLICATION FOR
PERMIT LIME GREEN
+' 76A364C
I hereby affirm that I have a certificate of consent to self insure,
or a certificate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING-'AIR CONDITIONING
copy there0i(Sec.3800 Lab. C.)
Policy No. Company COUNTY OF LOS ANGELES -DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
Certified copy is hereby furnished. �/
F-1Certifiedco Is filed with the count buildingins ection FOR APPLICANT TO FILL IN, BUILDING S 7 L S ���5
department. y P (PRINT OR TYPE ONLY) ADDRESS
,Date ApplicantLOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
CROSS
ABSORPTION COMPENSATION INSURANCE OR
PTION 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($100)or less.). AIR HANDLING UNIT,CFM DISTRICT NO.. PROCESSED 9Y
certify that in the performance of the work for which this permit
is issued, I.shall not employ any person in any manner so as to BOILER,BTU
become subject to the Workers' Compensation Laws. hh
COMPRESSOR,BTU
—1 6-
_ 4 APPROVALS DATE INSPECTOR'S SIGNATURE
Date � •) � r Applicant VENTILATION SYSTEM � -
NOTICE 10APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL —
provisions or this permit shall.be deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATION
I hereby affirm that I am licensed under.provisions of Chapter 9 HEATERSUSPENDED •UNIT
:
(Commencing with Section 7000)•of Division 3 of the Business and WALL
Professions Code,and my license is in full force and effect.
y�aa�� JMCy
License Number Lic.Class '
a.
Contractor �)C. r 1 )RE Date -.11-h/0 w O
® I am exempt under Sec. Plan Check feeV
a
B.&P.C.for this reason 1`C J PERMIT ISSUING FEE$ Lf Q �_
C'J 3_. O
c._ 0
r c�,pn� T r-IM. W
O Da TOTAL FEE � i;,-•�:
Signature �• - ...
Q 1�LLl
PLAN CHECK APPLICANT TOTAL I iz5 2 05 ,co
OWNER-BUILDER DECLARATION
Z
I hereby affirm that 1 am exempt from the Contractor's License Law NAME r W �� , IG t '• —°
for the following reason (Section 7031.5, Business and Professions ? r p IC : s'Ej'v"L
t €-
Code): I U� DCUS/ Ot ,
❑ ADDRESS
I, as owner.of the property, or my employees with wages
as,their sole compensation, will do the work and the CITY in TEL.NO. f1(
structure is not intended or offered for sale (Section 7044, V tii =ll _i I1 i`/
�i
Business and Professions Code). OWNER m YJx 1 _
L.
f_�-1�'
I, as owner of the property, am exclusively contracting MAIL (q f „p �
with licensed contractors to construct the project (Sec- ADDRESS (`s _ / (JCI
tion 7044, Business and Professions Code).
CITY TEL.NO.
CONSTRUCTION LENDING AGENCY
hereby affirm that there is a construction.lending agency for CONTRACTOR
the performance of the work for which this permit Is issued I\ %IIVt
(Sec.3097,Civ.C.).
Lender's Name ' ADDRESS 1(171YC QI Cour
p kA
CITY `4 TEL.N0. qV ) Y J
- .
'
Lender's Address STATE LIC.
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
property for i pection purposes. / SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNAT E OF PPLICANT OR AGENT ATE