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Home My Public Portal About9902 BOGUE ST_Mechanical__ o: WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT - insure, that I have a certificate of consent to self ', or a certificate of Workers' Compensation Insurance, , - HEATING - VENTILATING - AIR CONDITIONING Sr a certified copy thereof (Sec 3800, Lab C.) 76A364C CE-818(REV. 10/81 Policy No.-Company )' 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 �y q O Z �OC7UE s� tion department (PRINT OR TYPE ONLY) ADDRESS i Date Applicant LOCALITY T, L rT J NO TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST COMPENSATION INSURANCE CROSS ST j�L�lv1D.� BTU � DISTRICT NO PROCESS v (This section need not be completed if the'work involved by ABSORPTION UNIT, l the permit is for one hundred dollars ($100)or less.) • AIR HANDLING UNIT,CFM (�v certify that in the performance of the work for which this ' permit is Issued, I shall not employ any person In any manner BOILER, BTU so as to become.subject to the Workers'C mpens TORS SIGNATU E cc Z Q COMPRESSOR, BTU $ �� Z�1 ot90 '' ROUGH Date �`ZH` JApplica NOTICE.TO APPLICANT, If, after making 1 is Certificate 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 o U 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 my license Is in full force and effect. d License Number y 7 Z Lic Class G� Zc/ _ , V p.� 1'D 0 Contractor-GL-N- Date ` O ❑ �7 aatrTt_ET 5 1 N�-ETS V I am exempt under Sec d Plan check fee B 8P C for this reason N PERMIT ISSUING FEE $ /U Z Date' - EE Signature TOTAL F --O ER-BUILD R DECLARATION PLAN CHECK APPLICANT ._ I hereby affirm that I am exempt from the Contractor License , Law for the following reason (Section 7031 5, Business and NAME G L pk-qk�Lr--.{ `70wEi2 CO Professions Cocle)- " S _ sk'FflvhROaVc ❑ ADDRESS I, as owner of the-property, or my employees with 1 304 wages as their sole compensation;will do the work andc Q v TEL NO -3 I the structure is not intended or offered for sale(Section• CITY m0 0 7044, Business'and Professions Code). T•;I-!i, ❑ �Pt2��1�S81✓ . �. ....I, as owner of the property, am exclusively contracting OWNER, .D MAIL rt 1t -s with licensed contractors to construct the project (Sec- ADDRESS Q Q� jjQ wr j t��L 4 � tion 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY CITY �- L `.r 'TEL NO Z ca(,--2gZ3 I hereby affirm that there Is a construction lending agency forr It the performance of the work for which this permit is issued• CONTRACTOR (Sec 3097, Civ. C ) - - ADDRESS \—Z, S oGK fls'_h €-i 3€rI i'' Lender's Name Q _ _�� $ CITY {V..�Z-0 V 1 • \, TEL NO--,,0'!, Lender's Addressiir1€ " " STATE [] LIC I certify that I have read this application and state that the LICENSE NO LA '1 2•y OZ 'CLASS • above information is correct. I agree to comply with all County ordinances and State laws relating to building construction, and hereby authorize represen atives of this County to enter upon,th a ention perty for Inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE y _. 214 Signature of Applicant or Agent Date t- :l � KERS'COMPENSATION DECLARATION CEA 81 8(2- If L�80) A&_A CAT�®N" FOR I!—E UISUGU T ' $• _J. affirm that I have a' certificate of-consent to'self insure, or a certificate of Workers'Compensation Insurance,or HEATING-VENTILATING-AIR CONDITIONING a certified coov thereof(Sec. 3800,Lab.C.) /l Policy No/Z72793Campany ZW At I 1.1es Fl Certified copy is.he eby furnished. = COUNTY OF LOS ANGELES BUILDING ARID SAFETY Certified copy is filed with the county building''�spection FOR APPLICANT TO FILL IN, BUILDING `department. /� ' ADDRESS -qQ Date!.2 -Y-Y Applicant• (PRINT OR TYPE ONLY) LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE COMPENSATION INSURANCE NEAREST. } (Thissection need not be completed if the'work involved ABSORPTION.UNIT, BTU CROSS ST. hnZ� a0 by the permit is for one hundred dollars ($100) OI leis.) DISTRICT NO r) PROCES ED 8Y U :<- I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM r, 'ccpermit is issued, I shall not employ any person in any manner 15i O so as to become.subject to the Workers' Compensation Laws.. BOILER, BTU APPROVALS DATE INSPECTr f'S SIGNATURE U W Date Applicant COMPRESSOR,BTU ROUGH _ _ _ NOTICE TO APPLICANT: If,-after making this Certificate of VENTILATION SYSTEM FINAL v Z Exemption, you should become subject to the Workers' Compensation -provisions of.the Labdr Code,you must forth- EVAPORATIVE COOLER- m VALIDATION with comply.with such provisions or this permit shall.be - deemed revoked. FURNACE: FAU�/ t?RAVITY LICENSED CONTRACTORS DECLARATION , FLOOR: BTU_f�OI_OCU— (� I hereby affirm that I am licensed under provisions of Chapter HEATER: SUSPENDED UNITr) 4 f1 9 (commencing with Section 7000) of Division 3 of the Busi- WALL L ness and Professions Code, and,my.license is in full force and # 0,0'e ,* e 8 effect. �� o • y�2 Q License Number 7315 Lia Class O • • • J(J c=i Contractor�Qp��`� Date_A-t/,Y( � 2-1 2-$4 I am exempt from the licensing requirements as I am a! " licensed architect or a registered professional engineer Plan check fee 250 of above. acting in my professional capacity (Section 7051, Bus- iness and Prdfessions,Code). PERMIT ISSUING FEE $ Lie,or Reg.No. Date TOTAL FEE 7. HOME OWNER-BUILDER DECLARATION , -PLAN CHECK APPLICANT I hereby affirm that I am exempt from- the -Contractor's NAME License Law for the fol)owing reason (Section 7031.5, Busi- ness and Professions Code): ADDRESS 1, as owner of'the property, will do the work and the CITY TEL.NO: structure is ;not intended or offered'for sale (Section 7044, Business and Professions Code). MM_A 1_(� (Z: ❑ OWNER 1 : �<<'12 s 0,13 I, as owner of the,property, am exclusively.Contracting A with licensed contractors to construct-, the project MAIL (Section 7044, Business and Professions Code). ADDRESS CONSTRUCTION LENDING AGENCY CITY TEL. NO. I I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is, CONTRACTOR' C 7A1,C. issued(Sec. 3097.Civ.C.). Lender's Name _ ADDRESS I • - - ��_i-lam�N� �^► �"rA , Lender's Address CITY T`pN le Ct 1_� TEL. NO. I certify that I have read this application and state that the STATE 1 1- LIC. above information.is correct.I agree to comply with all County LICENSE NO. q 0373 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 " iusvPction purposes. Signatur_of Permittee Date