HomeMy Public PortalAbout9619 WOODRUFF AVE_Mechanical__ ION
WOthat I have
a certificate
of consent
76A348DPW9/89 APPLICATION FOR PERMITLIME GREEN
I herebjr affirm that I have a certtfioate of consent to self Insure, I78A364C ,
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 county building inspection FOR APPLICANT TO FILL IN BUILDING
dADDRESS
department. (PRINT OR TYPE ONLY)
Date Applicant LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CCC
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
CROSS
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($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. :E�D BY
I certify that in the performance oft work for which this perm(
is issued, I shall not employ any per on n any m ner so as t BOILER,BTbecome subject to the Workers'Com satian Law ) ����� ��
/ r 0
COMPRESSOR,BTU
r JQC, APPROVALS DATE INS; R'S SIGNATURE
Date Appllc t VENTILATION SYSTEM
NOTIdt TO APPLICANT: If, War making t is Certificate of
Exemption,you should become,subject to the Workers'Compensation I EVAPORATIVE COOLER ROUGH 16o t
provisions of the Labor Code,you must forthwith comply with such FINAL w _
provisions or this permit shall be deemed revoked. FURNACE: FAU I GR.AVITY
LICENSED CONTRACTORS DECLARATION IFLOOR BTU `!�J VALIDATION
1 hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT
(commencing with Section 7000)of Division 3 of the Business and I HEATER: WALL
Professions Code,and my license is In full force and effect.
. c
n ACCT o J .
License Number Lic.Class I r ,v77 3303 147.70 >
/ .. �� ® 1 ITEMS a
Contractor C
❑ I am exempt under Sec. I Plan check fee TOTAL IL47
BAP.C.for this reason PERMIT ISSUING FEE$ CHECK 147070 C
Date: CHANGE a 00 C
TOTAL FEE �C� til
Signature a
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT n
0000-0001 11/ 8/95 z
1 hereby affirm that I am exempt from the Contractor's License Law NAME ® 3216 1 PM17=11
for the fallowing reason(Section 7031.5, Business and Professions,
Code): ADDRESS
❑ 1, 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;
Business and Professions Code). OWN
ERE]
i ell—
I, as owner of the property, am exclusively contracting MAIL 11
with licensed contractors to construct the project (Sect ADDRESS V
tion 7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY TEL.NO. (/
I hereby affirm that there is a construction lending agency for I CONTRACTOR
the performance of the work for which this permit is issued
(Sec.3097,Civ.C.). I
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
reprosen Ives of this Co my to enter upon the above-mentioned ,
p arty or Inspectio rposas. SEE REVERSE FOR EXPLANATORY LANGUAGE
'0_ � _ � `�'
RE PPLI T AGENT f DATE