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HomeMy Public PortalAbout6236 AVON AVE_Mechanical__ %'O t RS'COMPENSATION DECLARATION 76A364C o 0 nno ((�� p (gi�pp o nno ((0�M�/� R' CE-898 (2-80) ��lf� L�Q���Q©Q�l Q=O� If� �U1SUVilQ� I"�'s >y�.i�rm that I have a' certificate of consent to self in c, or a certificate of Workers'Compensation Insurance,or HEATiNG-V(�(�j'�0L/,a'q'BNG-AIR CONDITO®II��'V`Nd a certified copy thereof(Sec. 3800,Lab.C.) PolicyCompany Certified copy is hereby furnished. COUNTY OF LOS ANGELES BWLDING AND SAFETY Certified copy is filed with the county building inspection A department. FOR APPLOCANT TO FILL Ilii DDR Date Applicant (PRINT OR TYPE ONLY) ADDRESS CERTIFICATE OF EXEMPTION FROM WORKERS' NO, TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALLTYWpD6/� COMPENSATION INSURANCE NEAREST 4�.a/�/ a (This section need not be Completed if the work involved ABSORPTION UNIT, BTU CROSS ST. O by the permit is for one hundred dollars ($100) or less.) DISTRICT NO. PROLE OB U I certify that 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 ✓/ CJ O so as to become subject to the Workers'Compensation Laws. BOILER, BTU �� I - APPROVALS DATE INSPE �OR'S SIGNATURE RE IU JI Date Lz Applic,- 8ACOMPRESSOR,BTU ROUGH 0. NOTICE TO APPLICANT: If, after making this Certificate of r— VENTILATION SYSTEM z Exemption, you should become subject to the Workers' FINAL Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDA ION with comply with such provisions or this permit shall be. deemed revoked. FURNACE; FAU GRAVITY LICENSED CONTRACTORS DECLARATION FLOOR: BTU I hereby affirm that I am licensed under provisions of Chapter HEATER: SUSPENDED UNIT 9 (commencing with Section 7000) of Division 3 of the Busi- WALL ness and Professions Code, and my license is in full force and LL effect. / ' -S" 1,V QAITLt License NumberWZ&� Lie.Classy (� f� T �4� Date Contracts.* � i' I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer- Plan check fee 25%of above. acting in my professional capacity (Section 7051, Bus- iness and Professions Code). PERMIT OS UING PEE $ v Lie.or Reg.No. Date TOTAL FEE J j HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT I hereby affirm that I am exempt from-the Contractor's NAME License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): ADDRESS .(„{w ❑ I, as owner of the property,will do the work and the structure is not intended or offered for sale (Section CITY TEL. NO. -7707 -.75 7044, Business and Professions Code). ❑ l=wt i- 1, as owner of the property, am exclusively contracting OWNER PESproject ro _ with licensed contractors to construct the P MAIL �7 Q T A# j`-ms" 5 s .•�r? s r (Section 7044,Business and Professions Code). 1ADDRESS`y.� (� TEL.NO. 15.75 CIT CONSTRUCTION LENDING AGENCY j �M PiL `i Z'S GS,o I hereby affirm that there is a construction lending agency r`�r, for the performance of the work for which this permit is COb/� 1�_ �rT�f� �JY � issued(Sec. 3097,Civ.C.). � �7vvj r6a�r� qr Lender's Name Lender's Address 4�4 //T �Y7 TEL.Ndn6__3 _ 13 lJ r Os I certify that I have read this application and state that the STATE LIC. '� Ail above information is correct.I agree to comply with all County LICENSE NO. CLASS ordinances and State laws regulating Heating, Ventilating and Air Conditioning,and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE County to enter upon the above-mentioned property for inspection rposes. � -/21 ,- Signature of Peittee Date rm YORKERS COMPENSATION DECLARATION APPLICATION FOR PERMIT ;I (firm that-�f'av�s-,cs certificate of consent to self In certificate of Workers Compensation Insurance HEATING - VENTILATING AIR CONDITIONING or a certif d copy thereof (Sec 3800 Lab C ) 76A364C ❑A y CJ CE 818(REV 10/81) Poll `Tf�� .�7�d['omparalr 7TiA� �i!/rl�..t/�5.Fated Certified copy is hereby furnished COUNTY OF LOS ANGELES BUILDING AND SAFETY Certified copy is filed with the county buiWing inspec FOR APPLICANT TO FILL IN BUILDING Aly 2 tion department (PRINT OR TYPE ONLY) ADDRESS ,V Date �^9a ApplIcc t ' 1% LOCALITY �+ / 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 permit is for one hundred dollars ($100)or less ) I certify that 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 IN ECTOR S SIGNATURE e Date .Applicant COMPRESSOR BTU � ROUGH NOTICE TO APPLICANT 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 VALIDAT ON with comply with such provisions or this permit shall be deemed revoked FURNACE FAUY 1 LICENSED CONTRACTORS DECLARATION FLOOR BTU GR V 4242112 OO I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED—UNIT— (commencing USPENDED UNIT(commencing with Section 7000) of Division 3 of the Business HEATER WALL and Professions Code and my license is In full force and effect d O License Number 3���-' Lic Class dgw_ V may/ ® � Contractor, &A /7a/� A615/ Date O u I am exempt under Sec f u>a Plan check feA d B 8P C for this reason Na PERMIT ISSUING FEE $ �� Z -3- Xgnatur . TOTAL FEE _ l OWNER BUILDER DECLARATION PLAN CHECK APPLICANT t " I hereby affirm that I am exempt from the Contractor s License Law for the following reason (Section 7031 5 Business and NAME a Professions Code) ' ❑ I as owner of the property or my employees with ADDRESS q - ACOT.T wages as their sole compensation will do the work and - ,307 20.50 the structure is not Intended or offered for sale(Section CITY TEL NO 7044 Business and Professions Code) — 1 ITEM ❑ OWNER - _ _ TOTAL 2� SO I as owner of the property am exclusively contracting +� + with licensed contractors to construct the project (Sec MAIL ` y tion 7044 Business and Professions Code) ADDRESS at CuEw�CK� 2.ma0+50 CONSTRUCTION LENDING AGENCY CITY �On �R r TEL N _ ' Q �.fV�`1uG .Oil I hereby affirm that there Is a construction lending agency for the performance of the work for which this permit is issued CONTRACTOR r (Sec 3097 Civ C ) -OW1 5/222/89 ADDRESS iAM a 7�1 A/� D Lender s Name 34" 1 M10e�7 4 CITY TEL N _ Lender s Address STATE LIC I certify that I have read this application and state that the I LICENSE NO CLASS _ above information is correct I agree to comply with all County ordinances and State jaws relating to building construction L and hereby authorize representatives of this County to enter up the ve nt r y for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent Date n J f� WORKER'S COMPENSATION DECLARATION 46 DPW 9/89 APPLICATION FOR PERMIT LIME GREEN 76A3 I hereby affirm that I have a certificate of consent to self insure, 76A364C ,or a`certificate of Worker's Compensation Insurance, or a certified HEATING -VENTILATING -AIR CONDITIONING copy thereof(Sec.3800 Lab.C.) Policy No. PP" 11'Ftompany S\ Q — Nq COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV. ❑ Certified copy is hereby furnished. BUILDINGDRESS �Z / Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN ADILDING!��(� department. //t� i�,,,,,,r� r!+ (PRINT OR TYPE ONLY) Date �JJ r Applicant / 1; r`t"--y "1W LOCALITY NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST COMPENSATION INSURANCE CROSS ST. 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 theperformance of the work for which this permit is issued, I shall not employ any person in any manner so as to BOILER,BTU v become subject to the Workers' Compensation Laws. QD COMPRESSOR,BTU Date Applicant VENTILATION SYSTEM APPROVALS DATE INSPECTOR'S SIGNATURE 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: FAU GRAVITY LICENSED CONTRACTORS DECLARATION FLOOR BTU 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: WALLProfessions Code, and my license is in full force and effect. License Number I I L Lic.Class /}�ltY , a Contractor Alt aVh Date �1' Q ❑ I am exempt under Sec. Plan Check fee Q B.&P.C.for this reason PERMIT ISSUING FEE Q Q Date: I TOTAL FEE DrT / W Signature 0- PLAN CHECK APPLICANT Cn OWNER-BUILDER DECLARATION Z I 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 ❑ S!: �S I, as owner of the property, or my employees with wages as their sole compensation, will do the work and the CITY TEL.NO. If? _vn4 structure is not intended or offered for sale (Section 7044, ,_.�t_ Business and Professions Code). OWNER � a4i 1 I'—f I3; ❑ 1, as owner of the property, am exclusively contracting CIT'1 )] MAIL Z 3 _ t Ai_ 3_ m 4•_[, with licensed contractors to construct the project (Sec- ADDRESS s� tion 7044, Business and Professions Code). �, '_• tk•i. I?o CONSTRUCTION LENDING AGENCY CITY C TEL.NO. �- _t_ $'6 s_ I hereby affirm that there is a construction lending agency for �tli3 the performance of the work for which this permit Is issued CONTRACTOR (Sec. 3097,Civ.C.). ADDRESS Z r _":III _• Lender's Name CITY 4L.NO. �J? Lender's Address 1 certify that I have read this application and state that the above LICE SE NO. ( CLASS information is correct. I agree to comply with all County ordinances and State laws relating to building construction,and hereby authorize representati of this County to enter upon the above-mentioned property f r spection purposes. r I K �y�[ SEE REVERSE FOR EXPLANATORY LANGUAGE l T t SIGNAT E P L AN AGENT DATE