HomeMy Public PortalAbout9845 LONGDEN AVE_Mechanical__ ION
WORKER'Shave a certificate
of consent to 211-0048DPW 9l89 APPLICATION FOR PERMIT LIME GREEN
_ 78A3f➢4C
I hereby affirm that I have a certificate of consent to self insure,
or a certificate of Worker's Compensation IOsurance, or a certified HEATING-VENTILATING-AIR CONDITIONING
copy thereof(Sec.GB00 Lab.C.) '
Poli Na` b q5 Company S6"4_ COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
Certified copy is hereby furnished. "-
Ce iftedpy is filed with the county building inspection FOR APPLICANT TO FILL IN UILDI
ADDRESS
d art R (PRINT OR TYPE ONLY)
Date Applicant r�,J• LOCALITY
NO. TY-E OE_APP�LIANCE OR EQUIPMENT FEE
NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST.
COMPENSATION INSURANCE ABSORPTION UNIT,BTU
(This section need not be completed If the work Involved by the ASSESSOR
PARCEL
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM MAP BOOK PAGE
DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU
become subject to the Workers'Compensation Laws. � J
COMPRESSOR,BTU
APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code,you must forthwith comply with such FINAL
L10-
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION I FLOOR BTU VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNI
(commencing with Section 7000)of Division 3 of the Business and WALL 0
Professions Code,andel my license is in full force and/effect.
License Number `� i Lic.Class `r 00 � y
EL
Contractor v Date ( �s C
❑ I am exempt under Sec. Plan Check fee C
a
B.&P.C.for this reason PERMIT ISSUING FEE$ J/ H
Date: TOTAL FEE u
Signature it
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT U
g G
1 hereby affirm that I am exempt from the Contractor's License Law NAME
for the following reason(Section 7031.5, Business and Professions 01111, ACCT.AV
°4
Code): ADDRESS -,
❑ I, as owner of the property, or my employees with wages 3+543 120°90
as their sole compensation, will do the work and the CITY TEL.NO. 1 ITEMS
structure is not intended or offered for sale (Section 7044, ,�h �7,
Business and Professions Code). OWNER TOTAL V 20 c 90
❑ I, as owner of the property, am exclusively contracting MAIL �' Vn 1 - CHECK 120-90
with licensed contractors to construct the project (Sec- ADDRESS 4S ( /` r- n
tion 7044,Business and Professions Code). CHANGE °00
CONSTRUCTION LENDING AGENCY CITYfj"LttAt% TEL.NO.�(� _
I hereby affirm that there is a construction lending agency for CONTRALTO .J rt
the performance;f the work for which this permit Is issued L LW QQ�Q—DUdi 7/1°/�ff1
Sec.3097,Civ.C.. u
Lender's Name
ADDRESS S _ khp 7559 1 PM 45
CITY /I TEL.NO.DES)bJ0 6+p1
Lender's Address v
I certify that I have read this application and state that the above LICENSE NO. 10 LIC.
!/v
information is correct. I agree to comply with all County ordinances
and State laws relating to building construction,and hereby authorize
reprentatives of this County enter upon t abovef�entioned
e y for pe i pur sea. �� /A SEE REVERSE FOR EXPLANATORY LANGUAGE
l(1/
SIGNATURE OF APPLI T OR A dT DATE