HomeMy Public PortalAbout9109 RANCHO REAL RD_Mechanical_1996-01-25 ION
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WORKER'S I have
a certificate
of cLARATION 76A34BDPW9/e9 APPLICATION FOR PERMIT LIME GREEN
1 hereby affirm that I have a certificate of consent to sf;lf insure, 76A364C
or a certificate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING
copy thereof(Sec.3800 Lab.C) 41,7z;wlge� u
Policy No��lk/G3J-25C 6p ny
El Certified copy is hereby furnished. COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
Certified copy is filed with the county building-in ctioIt FOR APPLICANT TO FILL IN BUILDING
�� SS /�
)department. ! (PRINT OR TYPE ONLY) ADDR
Date! � Applicant
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY
CERTIFICATE OF EXEMPTION FROM RKERS' NEAREST
CROSS ST.
COMPENSATION INSURANCE ABSORPTION 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($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU
become subject to the Workers'Compensation Laws.
COMPRESSOR,BTU
APPROVALS ATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code,you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: F GRAVITY / V LI ATION
LICENSED CONTRACTORS DECLARATION FLOOR BTU (p
1 hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
(commencing with Section 7000)of Division 3 of the Business and WALL
Professions Code,and mylicenseis in full force and effect.
License Number ` v LIC.Class
��� ►
Contractor Date C� 2S
❑ I am exempt u er sec. Plan check fee O
B.&P.C.for this reason PERMIT ISSUING FEE$
Date: TOTAL FEE ® LDL
Signature U
PLAN CHECK APPLICANT
OWNER-BUILDER DECLARATION eG
1 hereby affirm that I am exempt from the Contractor's License Law NAME ,
for the following reason (Section 7031.5, Business and Professions
Code): ADDRESS /�
El 1, as owner of the property, or my employees with wages ACCTeSa
as their sole compensation, will do the work and the CITY TEL.NO. 3303 53.90
structure is not intended or offered for sale(Section 7044,
Business and Professions Code). OWNER i 1 1 ITEMS
❑ I, as owner of the property, am exclusively contracting MAIL / �q TOTAL 53 .90
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044,Business and Professions Code). 9 G'AS'H 53.90
CONSTRUCTION LENDING AGENCY CITY ��X TEL.NO. 2�S '�/
I hereby affirm that there is a construction lending agency for CONTRACTOR �uA �G ���
the performance of the work for which this permit Is Issued
(Sec.3097,Civ.C.).
ADDRESS62.,—,�
Lender's Namn
e !/ 0000-0001 1/25/96
CITY TEL.NO.
Lender's AddressSTATE v �Z n 4436 1 AM10:41
7 C/
I certify that I have read this application and state that the above LICENSE NO. G CLASS
information is correct. I agree to Comply with all County ordinances
nd State laws relating to building construction,and hereby authorize
ativ oft (s-Eomrt enter upon the above-mentioned
7propeor' spection purpose . SEE REVERSE FOR EXPLANATORY LANGUAGE
Z/2 c
26" w -
SIGNATURE OF APPLICANT AGENT DAPE