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Home My Public Portal About9965 BOGUE ST_Mechanical__ t1RKERS'COMPENSATION DECLARATION 76A364C n - +� CE-_818 (2-80) LA PPUCATI O N FOR PE R INII T Ali eby affirm that have x'certificate of consent to self ',re, ora certificate of Workers'Compensation Insurance,orHEeHy.II ►G-d1=NYILATII��i-AI(� •C®N®IYI®NG(�l�sertified copy thereof(Sec.3800,Lab.G.) licy No.Z�_R—_ :ompany � a COUNTY OF LOS ANGELES BUILDING ARID SAFETY-'Certified copy is.hereby furnished. - • Certified copy is filed with the county building inspectionIF _ depar r�Pn FOR APPLICANT..TO FI.LL IN _ BUILDING P ADDRESS � 3E�►Ul�i Date-i___ pplicant_V_�r'-" (PRINT,OR TYPE ONLY) LOCALIT CERTIFICATE OF EXEMPTION FROM WORKERS'' r NO. TYPE OF APPLIANCE OR EQUIPMENT FEE -1 COMPENSATION INSURANCE " _ NEAREST (This-,section need not be completed if the work involved ABSORPTION UNIT, BTU CROSS ST. -] ems`)►�. 0 by, the permit is for one hundred dollars ($100)-or'less.) DISTRICT NO PROCESSED BY I certify that in the_performance of the work for which this AIR HANDLING UNIT,CFM } permit is issued,.I shall not employ any person in any,manner . . so as to'become subject to the Workers' Compensation Laws. BOILER, BTU V APPROVALS DATE INSPECTOR'S SIGNATURE ul Date Applicant ` COMPRESSOR,BTU 5.15 9 ROUGH �� ✓ n Cn NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL z Exemption, you should become subject to the Workers'' Compensationprovisions of the-Labor Code,-you must forth-' EVAPORATIVE COOLER VALIDATIO with •comply with. such provisions or•this permit shalt be - deemed revoked. FURNACE: FAUr R4VITY LICENSED CONTRACTORS DECLARATION ` FLOOR: I hereby affirm that I am licensed under provisions of Chapter HEATER: SUSPENDED UNIT 9 (commencing with Section 7000) of Division 3 of the Busi- WALL ness and Professions'Code, and my license is in'full force and effect: License Number___�6 T,�- Lic.Class e� Contractor� G�V�t.7 Date' `1�sU�_ ❑" I am exempt from the licensing requirements as I am a - licensed architect or a registered professional 'engineer Plan Check fee 25%of above. acting in'my professional capacity (Section 7051, Bus- ,4 iness and Professions Code). PERMIT ISSUING FEE'$ r 9'7 LI O A Lic,or Reg.No. Date TOTAL FEE fid. 3;_V ' #'o'o•'o'o 0, 8 - APPLICANT I HOME OWNER-BUILDER DECLARATION. PLAN CHECK'AI ' - _ - - .. 050 " I hereby affirm that I am exempt from the Contractor's NAME ,�j 2 -'-' 3 License Law for the following reason (Section 7031.5, Busi- - y• `7 �o Yo Io 3'0,5 0 ness and Professions Code): ADDRESS W-2 J> Q + r 1, as owner of the property, will do the work-and theo 3, 15."—8`4 • structure is not intended or offered for sale (Section_ CITY C-L��w�►w, TEL. NO.'S�1� � 7044",-Business and Professions Code). - - OWNER 0 I, as owner of the property, am exclusively contracting VN_ with licensed contractors to construct the project MAIL' (Section 7044, Business and Professions Code). ADDRESS CONSTRUCTION LENDING AGENCY CITNTEL.NO. - I hereby affirm that there is a construction lending agency CONTRACTOR- `�� for the per �7 formance of the work for which-this permit is ` issued(Sec. 3097,Civ:C.). Lender's Name ADDRESS Lender's Address CITY 1 ��,��, TEL.NO. I certify that I have read this application and state that.the STATE Q[=?t �4 CLASS abov ir" ration is correct'.I agree to comply with all County LICENSE NO. cic� ordi iar es an,' State laws regulating Heating, Ventilating and Air 'o,tit:onin,, and hr-eby authorize representatives of this SEE.REV ERSE FOR EXPLANATORY LANGUAGE Col ,t r ent,r up n `he above-mentioned properly for Mgnature of Permittee Date t' WORKERS'COMPENSATION DECLARATION 76A364C I_ hereF� .`effirm that I have a' certificate of consent to self CE-818 (2-80) APP� C AT�O �I FOR IT �UIS u iu�� inure, or�tifipate of Workers'Compensation Insurance,or ( HE:ATING-VENT ILATING.=AlR CONDITIONING a certified cobs thereof(Sec.380000�,Lab.C.) PolicyiVC�O/ _� ompanyi!7oe1 � •W T ❑ Certified copy js•hereby furnished". COUNTY OF LOSANGELES / BUILDING ARID SAFETY Certified copy is filed with the county building inspection BUILDING �-�. FOR APPLICARITTO FILL°IN �deuartmen ADDRESS �9�� , • D.i`An1Z. Appli - 'e (PRINT OR-TYPE,ONLY) f LOCALITYT G CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE 11 COMPENSATION INSURANCE _ NEAREST } (This section need .not, be completed if the work involved ABSORPTION UNIT, BTU CROSS ST. a0 -by the.permit is for 'one hundred dollars ($100) or less.) DISTRICT NO PROCESSED ,v U AIR HANDLING UNIT,CFM 1 certify that in the performance of the work for which this �� 0 permit is issued, I•shall not employ any person in any manner so as to become subject to the Workers' Compensatio1.n Laws BOILER, BTU / APPROVALS DATE INSPECTOR'S SIGNATURE W Date Applicant ` COMPRESSOR, BT,U*/ O / U ROUGH S^ — ._ Z NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM _ Exemption, you" should become subject to the Workers' FINAL Compensation provisions. of the Labor.Code, you must forth-. EVAPORATIVE COOLER VALIDATION with, comply with-'such provisions or this permit shall be / deemed revoked. ✓ 'r, FURNACE:• FAU RAVITY /0r�� LICENSED CONTRACTORS DECLARATION, / FLOOR: BTU-- UNI f0 I hereby affirm that I am licensed under provisions of Chapter HEATER: SUSPENDED UNIT 9 (commencing with Section 7900)of Division 3 of the Busi- WALL ness and Professions Code, and my license is in full force and effect. ' •�License �Numb�er 42?DAl?' Lic.Class,�.,0 vntracwi_ "'r�►�' �llate oI 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-ISSUING FEE $ _ ,s - Lic.or.Reg.No. -Date TOTAL FEE Q Sd HOME O)hIMER-BUILDER DECLARATION PLAN CHECK APPLICANT z0`44,,5'A ' I hereby affirm that I am exempt from- the Contractor's NAME License Law for the following reason (Section, 7031.5, Busi- o,e o 0 - 8 ness and Professions Code): ADDRESS i '' a1, as owner of the property, will do the work and theCITY TEL. NO. 3.0,,55 0 structure is not intended or offered for sale (Section. 0 0 I F77044, Business and Professions Code). �• •o I 30,50 OWNER 11I, as owner of the property; am exclusively contracting %:_ _ — — — r .with licensed contractors to construct the project MAIL !) 4:1 2,-.84 (Section 7044, Business and Professions Code). • ADDR-SS9� CONSTRUCTION LENDING AGENCY �j{/�� T 1I TEL.NO. ; I-hereby affirm that, there is a construction lending agency CONTRACTOR / ^ for the performance of the work for which this permit isxt��,} {e,�,� issued(Sec. 3097,Civ.C.). • Lender's Name ADDRESS Lender's Address I—V rEL. q I certify that I have read this application and state that, thegTAT,EZ- -t CLIC LASS above information is correct.I agree to comply with all County LICENSE NO. 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 �gn�t ection urpo +�ermrttee Date