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HomeMy Public PortalAbout4910 ARDSLEY DR_Mechanical__ WORKERS'COMPENSATION DECLARATION 76A364C p o �•}pp p p o 0 0 I hereby affirm that I have a' certificate of consent to self C=E 818 (2-80) Q� r L� C AT,u O U�l FOR [P E R llGll T insure, or a certificate of Workers'Compensation Insurance,or HEATONG-VENTILA71ING-91I R CONDMONOING a cert,fied croupy thereof tjS �r$Do,La C. Pol;cy No.! Groany m—• ''�11= � � Certified copy is hereby furnished, COUNTY OF LOS ANGELES 1 /�' ` BUJ-0 LDING ARID SAFETY Ev/.Certified copy is filed with the county building inspection BUILDING 'ne�IN FOR APPLICANT TO FILL BM. ! C/ n Date_` l.�Appl cant. 4 (PRINT OR TYPE ONLY) ADDRESS C O J[ ` LOCALITY �( CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT. FEE COMPENSATION INSURANCE NEAREST (This section need not be completed if the work involved ABSORPTION UNIT, BTU CROSSST. � /� �` w$/— 00 by the permit is for one hundred dollars ($100) or less.) DISTRICT NO. !!! PFOCE -D BY U 1 certify that in the performance of the•work for which this AIR HANDLING UNIT,C.FM t� (� permit is issued, I shall not employ any person in any manner ` Q so as to become subject to the Workers'Compensation Laws. BOILER,BTU APPROVALS DATE INSPECTOR'S SIGNATURE W Date Applicant COMPRESSOR,BTU •, LU /// ROUGH NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL '7 Exemption, you Should become subject to'the 'Workers' Compensation provisions of the Labor Code, you must forth- with comply with such provisions or this permit' shall be EVAPORATIVE COOLER VALIDATION deemed revoked. FURNACE: FAU GRAVITY­ LICENSED LICENSED CONTRACTORS DECLARATION FLOOR: BTU y/c� � I hereby affirm that I am licensed under provisions of Chapter f HEATER: ° '� IDED UNIT �O 9 (commencing with Section 7000) of Division 3 of the Busi- I WALL e_ 6-0 nest and Professions Code, and my license is in full force and {{ effect. ? ? [ License Number���%YjLic.Class^ / Contractor. Date QI am exempt from the• leensing requirements as I am a licensed architect or a registered professional engineer Plan Cheek fee 25%Of,above'. acting in my professional capacity (Section 7051, Bus- iness and Professions Code). PERMIT IISSUING FEE Lic.or Reg.No. Date TOTAL FEE .�� � HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT I hereby affirm that I am exempt from- the Contractor's NAME JV4W-1�'qq/R„� ' License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): ADDRESS I, as owner of the property, will do the work and the CITY C. TES. NO. structure is not intended or offered for sale (Section 7044,Business and Professions Code). I, as owner of the property, am exclusively contracting OWNER .'4'8 3, A 9 with licensed contractors to construct the- project MAIL (section 7044, Business and Professions Code). ADDRESS # o o•o 0 o 8, '. CONSTRUCTION LENDING AGENCY CITY TEL.NO. o••o 2 a 5 0, I'hereby affirm that there is a construction lending agency '/JA for the performance of the work for which this permit is CONTRACTOR = p P a 5,0 U issued(Sec. 3097,Civ.C.). t Lender's Name ADDRESS�`r // 10:471,'0'8'-8 2 Lender's Address CITY ✓�( C'(�• TEL. NO. �� 7 7 I certify that I have read this application and state that the STAT r—LIC. above information is correct.I agree to comply with all County LICENSE NO. 2 t/� YS CLASS I . ordinances and State laws regulating Heating, Ventilating and Air Conditioning, and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE Count- I enter ;,p a the oove-mentioned property for �'.- .arure of Permitt a Date WORKERS' COMPENSATION DECLARATION APPLICATION FOR PERMIT I hereby affirm that I have a certificate of consent to self insure, or a certificate of Workers' Compensation Insurance, _£ HEATING - VENTILATING - AIR CONDITIONING or,..a certif'`�d copy thereof (Sec. 3800, Lab. C.') 76A364C f '7�-� 20-0046 DPW 9/88 `Policy ir,o:' Company/ /L'�iJ ❑- Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY ❑ ,.Certified.copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING tion department. (PRINT OR TYPE ONLY) ADDRESS Date LU ApplicantJGLL�/!_ LOCALITY X NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST COMPENSATION INSURANCE CROSS ST. (This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT,NO. PROCESSED BY the per �'n�mit is for onehundred dollars ($100) or less.) I certifythat in the performance of the work for which this AIR HANDLING UNIT, CFM permit is issued, I shall not employ any person in any manner So as to become subject to the Workers' Compensation Laws. BOILER, BTU APPROVALS DATE INSPECTOR'S SIGNATURE Date t' Applicant /� '� J COMPRESSOR, BTU ROUGH Gi] NOTICE TO APPLI 'NT: If, after making this Certificate of VENTILATION SYSTEM FINAL Exemption,. you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION with comply with such provisions or this permit'shall be deem- ed revoked. FURNACE: FAU GRAVITY -LICENSED CONTRACTORS DECLARATION FLOOR BTU I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT— (commencing with Section 7000)of Division 3 of the Business WALL. �� and Professions Code,and`m�yllicense is in full force and effect. �tl rt' S~TD } License Number, Lic. Class , d Contractor Date I-110IL , le; 20 ❑ I am exempt under Sec. F- Plan check fee u W B.&P.C. for this reason. H Date: PERMIT ISSUING FEE $ Z Signature TOTAL FEE OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT I hereby affirm that I am exempt from the Contractor's License , Law for the following reason (Section 7031.5, Business and NAME t Professions Code): ' I, as owner of the property, or my employees with ADDRESS - wages as their sole compensation, will do the work and -x 7044, I°a the structure is not intended or offered for sale(Section CITY TEL. NO. 7044, Business and Professions Code). �Z 1_�Irr' �c i 11 f OWNER ❑ I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec- ADDRESS �� S�� 4TE S- tion 7044, Business and Professions Code). _ CONSTRUCTION LENDING AGENCYCITY 1' TEL. NO. ;ir�� 25 . 00 1 hereby affirm that there is a construction lending agency for C1 t''t, Oc' q the performance of the work for which this permit is issued '-`t°_"J P P CONTRACTOR �,.� Sec. 3097, Civ. C. CHANGE Lender's Name �l`�` — ADDRESS - Lender's Address CITY - 6 TEL. NOCJ��— ,D )_[., 1. # ii i f r 7t e Y i! I certify that I have read this application and state that the LICENSE NO. G- LIC.GTATE e 2-, CLASS Le'}�i' ;a° ^• above information is correct. I agree to comply with all County t4 �_ Nil 0°4•`• ordinances and State laws relating to building construction, and hereby authorize representatives of this County to enter upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE ` Signature of Applicant or Agent Date ©S