HomeMy Public PortalAbout9433 LONGDEN AVE_Mechanical__ ION
0-0046 DPW
WORKE'R'S have
a certificate
of consent to 76A364C 9f89 APPLICATION FOR PERMIT LINK S GUDD\\EEM
I herc�bY•L31tiPf(i Yfiat 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 thereof(Sec.3800 Lab.C.)
Policy No. Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
❑ Certified copy is hereby furnished.
❑ Certified copy is filed with the count building Inspection FOR APPLICANT TO FILL IN BUILDING
department. Y g P (PRINT OR TYPE ONLY) ADDRESS 433 LollAve .
Date Applicant LOCALITY
NO.tABSORPTION
OFAPPLIANCE OR EQUIPMENT FEE CNEARESTCERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST. CQIG �,
COMPENSATION INSURANCE UNIT,BTU(This section need not be completed if the work Involved by the ASSESSOR
ermit Is for one hundred dollars $100 or less. MAP BOOK fid. PAGE��� PARCELP ( ) ) NDLING UNIT,CFM DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU
become subject to the Workers'Compensation Laws.
COMPRESSOR.BTU
APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code,you must forthwith comply with such I FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY /
LICENSED CONTRACTORS DECLARATION FLOOR BTU (� O VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
(commencing with Section 7000)of Division 3 of the Business and WALL
Professions Code,and my license is in full force and effect.
License Number Lic.Class , ACCT°v }
A
Contractor Date 30`�1 ITEMS �`�°�� C
ElI am exempt under Sec. Plan Check fel
Q
B.ff,P.C.for this reason PERMIT ISSUING FEE$ TOTAL 93. 10 FC-
Date: TOTAL FEE CHECK q�°iQ LL
Signature CHANGE .00 a
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT V2,
1 hereby affirm that I am exempt from the Contractor's License Law NAME
for the following reason (Section 7031.6, Business and Professions 0000-0001 8/21/95
Code): ADDRESS 18'7[ i AM Oe 18
91 I, as owner of the property, or my employees with wages 17117 L FN t Cr rJ
as their sole compensation, will do the work and the CITY TEL.NO.
structure is not intended or offered for sale (Section 7044,
Business and Professions Code). -INNER Z Su
F1 1. as owner of the property, am exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRESS L_0w(rP p•�
tion 7044,Business and Professions Code). �p
CONSTRUCTION LENDING AGENCY CITY em TEL.NO. Zej 6V
I hereby affirm that there is a construction lending agency for CONTRACTOR ,
I performance of the work for which this permit Is issued
(Sec.3097,Civ.C.).
ADDRESS
Lender's Name
CITY TEL.NO.
Lender's Address STATE LIC.
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
representatives of this County to enter upon the above-mentioned
property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
l 22,
SIGNATF31 p�WORA.�� DATE