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HomeMy Public PortalAbout10250 RANDWICK DR_Mechanical__ ION 2D-00 Vm thatR'have a certificate of consent to 76A346DPW9/89 APPLICATION FOR PERMIT `SME GREEN, 76A384C 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-VENTILATIN--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. F1 Certified copy Is filed with the county building Inspection FOR APPLICANT TO FILL IN BUILDING department. (PRINT OR TYPE ONLY) LOCALITY `T��p�� Ge i� p Date Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEENEAREST d /t'�� CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST. G ra w�A A Z�S� uiCl��14,11A, COMPENSATION INSURANCE ABSORPTION UNIT,BTU (This section need not be completed if the Work Involved by the MAP OK PAGE PARCEL permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO. PROCESSED BY I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to I BOILER,BTU become subject to the Workers'Compensation Laws. c'�f� Qd ( A UL 41111V COMPRESSOR,BTU ©, APPROVALS DATE INSPECTOR'881GNATURE Date Applicant VENTILATION SYSTEM NOTICE TO APPLICANT: If, after making this Certificate of ROUGH 17 Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLE 7 provisions of the Lobar Code,you must forthwith comply with such c�-�7 FINAL ,? provisions or this permit shall be deemed revoked. FURNACE: FAU GRAV LICENSED CONTRACTORS DECLARATION / FLOOR BTU 5 VALIDATION I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT (commencing with Section 7000)of Division 3 of the Business and HEATER: WALL Professions Code,and my license is in full force and effect. u d6��7s c AN 8 ����� .�g 1'�4�r i e 4 License Number Lic.Class z� �Gs ---o— 102,013 Contractor L JN s 412 Date C /yT' ,D , i'EMM C 0 I am exempt under sec. Plan check fee TOTAL -1102 -00 C B.&P.C.for this reason PERMIT ISSUING FEE$ Q C��CK 102.011 H Date: f� TOTAL FEE 01, 00 CHANGE °00 u Signature 101k. 1142— fit/ PLAN CHECK APPLICANT !r OWN R-BUILDER DECLARATION 1 hereby affirm that I am exempt from the Contractor's License Law NAME for the following reason(Section 7031.5, Business and Professions '.e): 18eta 1 ACI116-1?c ❑ Codv_1 ADDRESS I, as owner of the property, or my employees with wages _ / as their sole compensation, will do the work and the CITY (�L /V06" TEL.NO. �� 6 structure is not intended or offered for sale(Section 7044, Business and Professions Code). OWNER ❑ 1, as owner of the property, am exclusively contracting MAILnn with licensed contractors to construct the project (Sec- ADDRESS f� '�.�p /42A vl�W/E k Of-'V- tion 7044,Business and Professions Code). CITY ; 7y�II'1�li TEL.NO. 7--7f—Z_Ca/ CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for CONTRACTOR .L IN S /G , the performance of the work for which this permit Is issued (Sec.3097,Civ.C.). ADDRESS 6 vf r T Lender's Name CITY •'0KI1b0 9A TEL.NO. q&l3 Lender's Address STATE LIC. I certify that I have read this application and state that the above LICENSE NO. �j �y 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 I F_-T pection SEE REVERSE FOR EXPLANATORY LANGUAGE 2//� F qP OR AGENT DATE