HomeMy Public PortalAbout5030 RYLAND AVE_Mechanical__ ION
WORKER'S I have
a certificate
of consent to 7OA34sDPW9/e9 APPLICATION FOR PERMIT LIME GREEN
76A364C
I hereby affinh�that I have a certificate of consent to self insure,
or s 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 county building inspection FOR APPLICANT TO FILL IN ADDRESS �y D�L�
department. (PRINT OR TYPE ONLY)
Date ApplicantLOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS
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($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is Issued, I shall not employ any person In any manner so as to BOILER.BTU
become subject to the Workers'Compensation Laws.
COMPRESSOR,BTU
APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code,you must forthwith comply with such v FINAL _217
provisions or this permit shall be deemed revoked. FURNACE: FAU b ,l�b VALIDATION
LICENSED CONTRACTORS DECLARATION FLOOR BTU 7
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT
(commencing with Section 7000)of Division 3 of the Business and HEATER: WALL
Professions Code,and my license is in full force and effect.
7d
License Number Lic.Class Ire
OL
Contractor Date ,Gl C
❑ Plan check fee
I am exempt under Sec. a
ACCi e,r a
BAP.C.for this reason PERMIT ISSUING FEE$ ��_(�/J �J C
Date. LLV( f( OUC
TOTAL FEE 1 �Tt�l LL
Signature PLAN CHECK APPLICANT ` c U
OWNER-BUILDER DECLARATION TOTAL 97 m 9_s G
1 hereby affirm that I am exempt from the Contractor's License Law NAME ® CHECK 970.
for the following reason(Section 7031.5, Business and Professions
Code): ADDRESS CHANGE a l!I]
I, as owner of the property, or my employees with wages
as their sole compensation, will do the work and the CITY TEL.NO.
structure is not intended or offered for sale (Section 7044, 0000_0001 3/31/9,3
/ Business and Professions Code). OWNER
1, as owner of the property, am exclusively contracting MAIL .t— 297-s 1 PM112:14
with licensed contractors to construct the project (Sec- ADDRESS v Q317 �
tion 7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY CIT TEL.NO.
I hereby affirm that there is a construction lending agency for CONTRACTOR ,
the performance of the work for which this permit Is issued
(Sec.3097,Civ.C.).
ADDRESS
Lender's Name
PATE
EL.NO.
Lender's Address LIC.
I certify that I have read this application and state that the above ENSE NO. CLASS
information is correct. I agree to comply with all County ordinances
and State laws re ting to building construction,and hereby authorize
repres tatives f this u ty to enter upon the abov -mentioned
prope t for i pectio pu oses. SEE REVERSE FOR EXPLANATORY LANGUAGE
If—VT
OTESI N RE OF APPLICANT O