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Home My Public Portal About9437 BLACKLEY ST_Mechanical__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT I hereby affirm that I have d'certificate of consent to self insure, or a certificate of Workers',Compensation Insurance, ,sA3a4c HEATING - VENTILATING - AIR CONDITIONING, or a certifie co y thereof (Sec 3800, Lab ) / CE 818(REV 10/81) Poll Nc) mpany G ❑ Certified copy is hereby furnished COUNTY OF LOS ANGELES - BUILDING AND SAFETY Certified copy is filed with the cou I In spec- FOR APPLICANT TO FILL IN BUILDING `7431'z, 2� hon department (PRINT OR TYPE ONLY) ADDRESSJ LOCALITY G/ Date - L 6 r Appllc NO TYPE OF APPLIANCE OR EQUIPMENT FEE , CERTIFICATE OF EXE PTION FROM WORKERS' NEAREST COMPENSATION INSURANCE CROSS ST (This section need not be completed if the work involved by ABSORPTION UNIT BTU DISTRICTNO / PRO)BY the permit is for one hundred dollars ($100)or less ) AIR HANDLING UNIT, CFM I certify that m'the performance of the work for which this cJ i v permit is Issued, I shall not employ any person i wany manner BOILER, BTU so as to become subject to the Workers"Compensation Laws w APPROVALS DATE INSP CTOR S SIGNATURE Date Applicant COMPRESSOR BTU I ROUGH,, J 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 A 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 9 HEATER SUSPENDED—UNIT— (commencing USPENDED UNIT(commencing with Section 7000) of Division 3 of the Business WALL and Professions Code, and my license Is in full force and effect } License Number 2 d / /Lic Class p^� - JIM oil / v Controcto0 �'�'�/•'Date ❑ 600 I am exempt under Sec - V Plan check fee d V/ B 8P C for this reason Z PERMIT ISSUING FEE $ to TOTAL FEE1310 , Sign A OWNER-BUILDER CLARATION PLAN CHECK APPLICANT I here y affirm that I am exempt from the Contractor's License - - / Law for the following reason (Section 7031 5, Business and NAME L � f fli( Professions Code) 1 `a� ❑ ADDRESS '/ I, as owner of the property,` or my employees with I ITEME wages as their sole compensation,"will do the work and 00 the structure is not Intended or offered for sale(Section CITY �`C TEL NI_ITw'iL m Q 7044, Business and Professions Code) OWNER "—� CT EEK 41,30 ❑ I, as owner of the property, am exclusively contracting MAIL CHANGE with licensed contractors to construct the project (Sec- ADDRESS y t` �lY�� .01,tion 7044, Business and Professions Code) CONSTRUCTION LENDING AGENCY CITY ~f�i TEL N I hereby affirm that there Is a construction lending agency for �` / (�'jl�0_ 1 1'26"7t3 the performance of the work for which this permit Is Issued CONTRACTOR'Z1 i �j! �a,�/S poll, �_,� (Sec 3097, Civ' C ) , 3 136" 1 AN 1[I e - ADDRESS }/ � - - -- � Lender's Name CITY �� TEL N ^/ Lender's Address STATE LIC X117 I certify that I have read this application and state that the LICENSE NO 2-0 CLASS Jy +above information is corr agree to comply with all County ordinances and ws rel g t bui mg construction, - and a onze repre ntative s County to enter upon�the Ove-mention pr or Inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE _ Ignature of Applicant or Agent Date ' ' WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT I hereby affi+m that I have a certificate of consent to self insure, or a certificate of Workers' Compensation Insurance, HEATING VENTILATING AIR CONDITIONING or a certified copy thereof (Sec. 3800, Lab. C.) 76A364C CE-818(REV. 10/81) Policy No. Companyertified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY C Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING tion department. ADDRESS (PRINT OR TYPE ONLY) Date Applicant LOCALITY NO TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST COMPENSATION INSURANCE CROSS ST. ABSORPTION UNIT, BTU DISTRICT NO. PROCESSED BY (This section need not be completed if the work involved by the permit is for one hundred dollars ($100)or less.) AIR HANDLING UNIT, CFM I certify that in the performance of the work for which this i ! 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 iNs CTOR'S SIGNATURE 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 VALIDATION 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 9 HEATER: SUSPENDED-UNIT- (commencing USPENDED UNIT(commencing with Section 7000) of Division 3 of the Business WALL a and Professions Code, and my license is in full force and effect. O License Number Lic. Class , ut J Contractor f Date LL. Y ❑ -I am exempt under Sec. Q Plan check fee ac B.&P.C. for this reason PERMIT ISSUING FEE $ CL 1. Date:- TOTAL FEE UJ Signature ~- 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 Professions Code): ❑ I, as owner of the property, or my employees with ADDRESS f wages as their sole compensation, will do the work and - the structure is not intended or offered for sale(Section CITY TEL. NO 7044, Businos and Professions Code). OWNER ❑ I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec- MAIL i tion 7044, Business and Professions Code). ADDRESS CONSTRUCTION LENDING AGENCY CITY TEL. NO. I hereby affirm that there is a construction lending agency for ► the performance of the work for which this permit is issued CONTRACTOR (Sec. 3097, Civ. C.). i ' ADDRESS Lender's Name CITY TEL. NO.- Lender's Address , I certify that I have read this application and state that the STATE LIC. LICENSE NO. CLASS above 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 property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Sjpaature of Applicant or Agent Date