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Home My Public Portal About9064 BROADWAY_Mechanical__ .. r"IVCaRKERS'COMPENSATION DECLARATION APPLICATION PPA ICA TION FOR PERMIT• - PY IL P9 U(�M7 Y Thereby affirm that I oa�re o certificate of consent to self ' insure, or a certificate of Workers'Compensation Insurance, 7EA8a4C HEATING - -VENTILATING AIR CONDITIONING or a certified copy thereof (Sec 3800, Lab. C.) -I 7 CE-818(REV. 10/81) — - Policy No.r . 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 tion department. (PRINT OR TYPE ONLY) ADDRESS Date Applicant - LOCALITY 4"7 NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST COMPENSATION INSURANCE CROSS Si. (This section need not be completed if the work involved by ABSORPTION.UNIT, BTU DISTRICT NO. RROCESSED BY the permit is for one hundred dollars($100)or less.) .� K 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 APRRovAtsonrr INSTORS SIGNATURE Date Applicot COMPRESSOR, BTU ROUGH NOTICE TO APPLICANT: If, after mokibg this Certificate of VENTILATION SYSTEM FINAL / v Exemption, you. should become subject to the Workers' - Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDA ON with comply with such provisions or this permit shall be deemed revoked. - FURNACE: FAU_GRAVITV LICENSED CONTRACTORS DECLARATION FLOOR BTU I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPEN ED UNIT_ - �) /p, '(commencing with Section 7000) of Division 3 of the Business WALL (� (�(J and Professions Code,and my license is in full force and effect.' R License Number- Lic. Class' Contractor Date - O V ❑ I am exempt under Sec Plan check fee Q,8It B.BP.C. for this reason' PERMIT ISSUING FEE $ �U ,� e e'e,e e 8 Z Dale:SigJ e • 30,50_natur TOTAL FEE e e e 3 0,5 0 U OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT I hereby affirm that I am exempt from the Contractors License D ( t 0`��8 8 Law for the following reason (Section 7031.5, Business and NAME Professions �� Code): - (J(J 1, as owner of the property, or my employees with ADDRESS \ wages as their sole compensation,will do the work and the structure is not intended or offered for sale(Section CITY TEL. NO. 7044, Business and Professions Code). - ' OWNER d.il198�� ❑ I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec- MAIL tion 7044, Business and Professions Code). ADDRESS CONSTRUCTION LENDING AGENCY CITTEL 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.). , ADDRESS Leader 5 Name ' CITY TEL. NO. Lender's Address ' STATE LIC. I certify that I have read this application and statethat the LICENSE NO. CLASS - above information is correct.1 agree to comply with ott County ordinances and State laws relating to building construction,. and hereby authorize representatives of this County to enter ' the above=menti oned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent Dale "- - - WORKER'S I have a certificate DECLARATION ��DPW 9/89 APPLICATION FOR PERMIT GREEN I hereby affirm that I have a certificate of consent to self insure, p n�`-� Or a certificate of Worker's Compensation Insurance, or a certified HEATING •VENTILATING •AIR CONDITIONING copy thereof(Sec.3800 Lab. C.) Policy No. Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV. Certified copy is hereby furnished. ❑ Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN DILOING A department. (PRINT OR TYPE ONLY) ADDRESS Date Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST CROSS ST. COMPENSATION INSURANCE 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($100)or less.) AIR HANDLING UNIT,CFM olsmlcT No. PRocEsseD BY I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to BOILER,BTU - become subject to the Workers' Compensation Laws. - - COMPRESSOR,BTU APPROVALS OAIE INSPECTOn'3616NATUflE Date Applicant VENTILATION SYSTEM NOTICE TO APPLICANT: If, atter making this Certificate of ROUGH Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER provisions of the Labor Code, you must forthwith comply with such FINAL provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATION I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED—UNIT— (commencing USPENDED UNIT_(commencing with Section 7000) of Division 3 of the Business and HEATER: WALL Professions Code,and my license is in full force and effect. License Number Lia Class �yy--}}��,,�-�g�s i *7iSrJa] 31. d Contractor Date T r,kaqrr*� Q ❑ am exempt under Sec. PIBR Check fee '�' A? ITEAS « k. W B.BP.C.for this reason PERMIT ISSUING FEE$ i%. -.-.2 0019. LL Date: TOTAL FEE 3e. > Signature Ir OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT �yry�L y� ¢¢A Q I hereby affirm that I am exempt from the Contractor's License Law NAME , � 151, d for the following reason (Section 7031.5, Business and Professions �6 EL Code): 62M b 1" LLI I, as owner of the property, or my employees with wages as their sole compensation, will do the work and the CITY TEL.NO. structure is not intended or offered for sale(Section 7044, Business and Professions Code). OWNER ❑ I, as owner of the property, am exclusively contracting MAIL with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY CITY TEL.NO. I hereby affirm that there is a construction lending agency for CONTRACTOR , the performance of the work for which this permit Is issued (Sec.3097,Civ.C.). ADDRESS Lender's Name CITY TEL.NO. Lender's Address STATE LIC. I certify that I have read this application and state that the above LICENSE NO. CLASS 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 SIGNATURE OF APPLICANT OR AGENT DATE WORKER'S h ve a certificate SATION DECLARATION 76A364 DPW 9/89 APPLICATION FOR PERMIT �.OME GREEN 0-0046 I hereby affirm that I have a certificate of consent to self insure, or a certificate of Worker's Compensation Insurance, or a certified - HEATING - VENTILATING -AIR CONDITIONING copy thereof(Sec.3800 Lab.C.) , Policy No. Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV. ❑ Cenified.capy is hereby furnished ❑ Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN BUILDING ' department. � (PRINT OR TYPE ONLY) ADDRESS �` 2Q QLyP5 /qU Date Applicant LOCALITY o NO. TYPE OF APPLIANCE OR EOUIPMENT FEE <-F G .� CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST COMPENSATION INSURANCE ABSORPTION UNIT,BTU CROSS ST. ,S UL7- N/}- , Qpr/ (This settlor need not be completed [ha work Involved by the - ASSESSOR MAP BOOK ✓J/ PAGOb� PARCFB/O permit is for one hundred the 0 or less.) c AIR HANDLING UNIT,CFM DISTRICT No. • PROCESBED By I certify that in the performanceonce off the work for which this permit is issued, I shall not employ any person in any manner so as to BOILER,BTU ) (rte become subject to the Workers' Compensation Laws. COMPRESSOR,BTU GGZZ" _Date 5 -3- `iL Applicant H r,<Hi Nw R m I N.S Z M?nWALa HATE 'INSPECIDP'a SxiNATUPE/ VENTILATION SYSTEM NOTICE TO APPLICANT: If; attar 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 shell.be deemed revoked. FURNACE ' FAU GRAVITY LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDA ION 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: WALL �i/A� p _Professions Code,and my license is in full force and effect. 'J l%�• V v Llir� 1 r License Number d-1 �O� Lic.Class. ACCT•T l-f9;4m6,, R//AU/(Quate 5 3-`� G D 3303 31.50 a Ic�ornradar 1 ITEM O LJ 1 am exempt under Sec. Plan check fee V B.BP.C.for this reason A/n EFn.PLa ,SPERMIT ISSUING FEE$,;27 30�. p TOTAL 31 .50 Q5 O oat : �,G CHECK 31.. 0 0 TOTAL FEE S70 Slgnalure ..oma.,__ "z� CHANGE .00 (L a PLAN CHECK APPLICANT (n OWNER-BUILDER DECLARATION •- Z I hereby affirm that I am exempt from the Contractor's License Law NAME D OD00'OOD1 5/ 3/96 for the following reason (Section 7031.5, Business and Professions 6204 1 AM10:20 Cade): ADDRESS ❑ I, as owner of the property, or my employees with wages _ as their sole compensation, will do the work and the CITY - TEL.NO. structure is not intended or offered for sale (Section 7044, - Business and Professions Code), OWNER 1-oNN t ,p NP0Ap T ❑ I, as owner of the property, am exclusively contracting MAIL fl ,t / with licensed contractors to construct the project (Sec- ADDRESS .106 2eHD 1ti (/S' tion 7044, Business and Professions Code). - TEL.NO. � -CONSTRUCTION LENDING AGENCY c"Tp L E S- I hereby affirm that there is a construction lending agency for CONTRACTOR D the performance of the work for which this permit Is issued (Sec.3097,Civ.C.).. ADDRESS Lender's Name ' CITYG LIFTEL.NO.' 2 -c� Z .• . Lender's Address STATE LIC. ✓ - - I certify that I have read this application and stale that the above LICENSE NO. �Iya/D CLASS - - 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 - - p operty for inspection pur oses. - SEE REVERSE FOR EXPLANATORY LANGUAGE c;e � S-3-�G SIGNATURE OF APPLICANT D AGENT DATE