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Home My Public Portal About9008 - 9010 BROADWAY_Mechanical__ DEC WORKERS' COMPENSATION cafe ofI�onse APPLICATION FOR PERMIT 1 hereby affirm that I have a certificate of consent to self insure, or a certificate of Workers' Compensation Insurance, or a certified76A364C HEATING - VENTILATING - AIR CONDITIONING + ,copy thereof&c. 3800, Lab. C.j Policy 1 thA.P y �` r• 20-00DPW 9/88 ❑ Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY Certified copy is filed with the county building spec- BUILDING ` ❑ FOR APPLICANT TO FILL IN ` �V6 tion department. ADDRESS 6 W (PRINT OR TYPE ONLY) Date Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY C RTIFI ATE 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. PR SLED BY the permit is for one hundred dollars ($100) or less.) f", O� I certify that in the performance of the work for which this AIR HANDLING UNIT, CFM_ `"Jl permit is issued, 1 shall not employ any person in y manner so as to become subject to the Wor re mpe tion Laws. BOILER, BTU APPROVALS DATE INSP CTOR'S SIGNATURE COMPRESSOR, BTU ROUGH Date Applicant NOTICE 4 AP INL CA 'If, fl -aev akg this inCertificate 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. , t .I i 1, FURNACE: FAU_GRAVITY ~lrU/ LICENSED CONTRACTORS DECLARATION FLOOR BTU I hereby affirm That I am licensed under provisions of Chapter 9HEATERSUSPENDED UNIT : (commencing with Section 7000)of Division Sof the Business' - 'WALI-- - and Professions Code,and my license is in full force and effect. r > 5�a 3oc� License Number Lic. Class QT,P ov\A e , Ov Contractor�P r�ate 7 �-- W ❑ - I am exempt under Sec. V Plan check fee B.BP.C. for this reason ry a Date: PERMIT ISSUING FEE $ z Signat rPTOTAL FEE OWNER-BUILDER D'CLARATION 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 a wages as their sole compensation, will do the work and X14{�I a the structure is not intended or offered for sale(Section CIN TEL:NO ^ 301 ll '7 ,ii 7044, Business and Professions Code). OWNER \ ❑ 1, as owner of the property, am exclusively contracting �+ 6LVll 1 with licensed contractors to construct the project (Sec- MAIL ADDRESS C TOTAL �, 25- 00 tion 7044, Business and Professions Code). CONSTRUCTION 2 LENDING AGENCY �0�� -,� CHECK 25.00 hereby affirm that there is a construction CIN ✓h TEL. NO,lending agency for CHANGE t th(Sec. 3097, Civ. C.).e performance of the work for which this permit is issued CONTRACTOR `� - 11111. CHANGE .III] ADDRESS Lender's Name II I[t[f=Q[i[li 3/ vi Y[I crry Q }^y- `3 o. �L Lender's Address �� -TA FE LIC. '11 1 �41�J 1 A�11�L:I certify that have read this application and state that the 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 Ott ave-m ntioned property for inaction purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applican or Agent ' DotA Cs WORKERS' COMPENSATION DECLARATION APPLICATION FOR PERMIT I hereby affirm that L rf War ce'.Comp of consent to self ^ insure, ora certificate of Workers'.38 0, Lob. cation Insural;ce, ' or o certified copy thereof (Sec. 3800, Lab. C.) � i6A364C HEATING = VENTILATING - AIR CONDITIONING P2557=. C.A. IDEMTfY 20-0046 DPW 9/88 l Policy No. Company i ❑ Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY Certified copy is filed with the county building inspec- OAe-ter n,,,� z FOR APPLICANT TO FILL IN BUILDING tion dep finent. > _ I (PRINT OR TYPE ONLY) ADDRESS Date ' } Applicant LOCALITY TEMPLE CITY NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CER FICA7E OF EXEM 10 OM J ORP. RS' NEAREST COMPENSATIOWNSURANCE CROSS ST. ROSEMEAD BTU (This action need not be completed the work Involved by ABSORPTION UNIT, DISTRICT 10 / P E ED ev' the permit Is for one hundred dollars ($100)or less.) 1 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 Lows. BOILER, BTU APPROVALS DATE INSPECTOR'S SIGNATURE Date Applicant M 6 M Ena neelun,9 COMPRESSOR, BTU 30,000 ROUGH NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL i Exemption, you should become subject to the Workers' 1r^1 My Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALID)kTfObi 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 my license is in full force and effect. 1 REST ROOM EX UST FAN - - } 0- License Number 405 Lic. Class I - y� , O Contractor M 6 M En,q<fneQlLClfd1e O ❑ I am exempt under Sec. Plan check fee B.BP.C. for this reason Q.Q Date: PERMIT ISSUING FEE $ un Signature TOTAL FEE 130,50 O E UILDER CLARA ION PLAN CHECK APPLICANT M 6 M En .en.eml n. I hereby affirm t am exempt from the Contractor's License , Law for the following reason (Section 7031.5, Business and NAME Joseph Maeko Professions Code): ❑ 1, as owner of the property, or my employees with ADDRESS 228 ti Ave. A wages as their sole compensation, will do the work and ACCT.r the structure is not intended or offered for sale(Section CITYAZLI/Sa TEL. NO,81 8-969-.9698 3307 30.50 7044, Business and Professions Code). F-] 1, as owner of the property, am exclusively contracting OWNER SHELL OI'L I ITEMS with licensed contractors to construct the project (Sec- MAIL ADDRESS TOTAL AL .J� a cVf-t tion 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY CITY HOUSTON, TEXAS TEL. NO. CHECK 30.50 I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued CONTRACTORM 6 M ENGINEERING , - CW4GE Oct, (Sec. 3097, Civ. C.). ADDRESS 228 MQTOR AVE. Lender's Name p01J0—IJL,HyI I?/29/+.7 CITY AZUSA CA Et. No. Lender's Address pe.? I certifythat I have read this application and stale that the STATE 4-15405 7�•a` 1 AM 9C[li above information is correct, agree to comply with all County LICENSE NO. CLASS C-40 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 n ur f Appf oN r Agent es