HomeMy Public PortalAbout9568 LAS TUNAS DR_Mechanical__ TIWN
WORKER'Shave a certificate'of
consent to 76A346DPW9/89 APPLICATION FOR PERMIT LIME GREEN,
I hereby affirm that I have a certificate of consent to self Insure, 76A364C
or a certificate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING -AIR CONDITIONING
copy thereof(Sec 3800 Lab C) - u
Policy No Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.'
F1 Certified,copy is hereby furnished •
DI
F] Certified copy Is filed with the county building inspection FOR APPLICANT TO FILL IN ADDRE S
department - (PRINT OR TYPE ONLY)
Date Applicant LOCALITY
NO TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS', NEARESTCROSS ST
COMPENSATION INSURANCE ABSORPTION UNIT,BTU
(This section need not be completed If the work involved by the ASSESSOR
MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO PROCESSED BY
I certify that in the performance of the work for which this permit
Is issued, I shall not employ-any'person In any manner so as to BOILER,BTU
become subject to the Workers'Compensation Laws
Date 9,Z �� / COMPRESSOR BTU
VENTILATION SYSTEM APPROVALS DATE INSPECTOR'S SIGNATURE
Applicarii-��
NOTICE TO APPLICANT If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers' Compensation EVAPORATIVE COOLER
42
provisions'of the Labor Code, you must forthwith comply with such FINAL 7
provisions or this permit shall be deemed revoked FURNACE FAU RAVITY p�
LICENSED CONTRACTORS DECLARATION FLOOR BTU � J VALIDATION
I hereby affirm that I am-licensed under provisions of Chapter 9 HEATER SUSPENDED UNIT
(commencing with Section 7000)of Division 3 of the Business and WALL
Professions Code,andmylicense is in full force and effect
License'Number ✓ 6iZ Lic Class
CL
Ir
Ir Contractor ® l�`h Date Y.2 - - O
,�
F-1I am exempt under Sec Plan check fee _ 17 _ _; Q
B&P C for this reason PERMIT ISSUING FEE$ /� ,� i{EM'_,
Date ;;grA 7x a p� V
TOTAL FEE �• . _ r�ttf_ a � � .�-_ � aW
Signature PLAN CHECK APPLICANT t1 ,s=i
OWNER-BUILDER DECLARATION Z
xE•M�
I hereby affirm that I am exempt from the Contractor's License Law NAME ' 3 `t(GE
for the following reason (Section 7031 5, Business and'Professions
Code) ADDRESS `
❑ I, as owner of the property, or my employees with wages I_( !!( ) j�{ < �:'L
as their sole compensation, will do the work and the CITY TEL NO " y
structure is not Intended or offered for sale (Section 7044, `, s j ;?;
Business and Professions Code) OWNER
❑ 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) CITY TEL NQS
CONSTRUCTION LENDING AGENCY
hereby affirm that there Is a construction lending agency for
I CONTRACTOR
I performance of the work for which this permit Is Issued ,
(Sec 3097, Civ C) , 1
ADDRESS l..�D -• - -_ _ - yL '
Lender's Name c�
CITY TEL NO y:�-o�f _
Lender's Address S ATELIC
I certify that I have read this application and state that the above LICENSE NO r 411Z_ CLASS Cr
information Is correct I agree to comply with all County ordinances n
and State laws relating to building construction,and hereby authorize
representatives of this County to enter upon the above-mentioned
property for Inspection purposes 7SEE REVERSE FOR EXPLANATORY LANGUAGE
S1GNATLIRI?1CF_AFWLIC,k1NT OR AGENT �� DATE ` ' ^