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Home My Public Portal About9108 BROADWAY_Mechanical__ WORKER'S COMPENSATION DECLARATION 20-0046 DPW 9189 APPLICATION FOR PERMIT ff �ME GREEN ]BA364C p7 II�L u'AU6}u+ 1/1/Vti-I it'll\\UI II I hereby affirm that I have a certificate ai 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. i 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 BUILDING n��A�i department. - (PRINT OR TYPE ONLY) ADDRESS [(� Date - Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY �./dC� e TY CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST nO/S/r/„J d�CROSS ST. F C/-f ,l /COMPENSATION INSURANCE ABSORPTION UNIT,BTU(This section neetl not be completed ii the work involvetl by the ASSESSORMAP BOOK PAGE permit is for one a performance an dollars f the or less.) AIR HANDLING UNIT,CFM OISTR6l No. PnoCESSEDer 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 �D4 become subject to the Workers'Compensation Laws. COMPRESSOR.BTU bD APPROVALS DATE INSPECTORS SIGNATURE Date Applicant 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 shall be deemed revoked. FURNACE: FAUGRAVn`e LICENSED CONTRACTORS DECLARATION FLOOR BTU_ o 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: Professions Code,and my license is in full force and effect. WALL License Number Lic.Class D Contractor Date aV F11 am exempt under Sec. Plan Check fee 0 SAP.C.for this reason PERMIT ISSUING FEE $ O Date: TOTAL FEE 3 �b a Signature EL PLAN CHECK APPLICANT �/� OWNER-BUILDER DECLARATION ,rTV Z I hereby affirm that I am exempt from the Contractor's License Lew NAME D for the following reason (Section 7031.5, Business and ProfessionsFRAG _ Code): ADDRESS /1 .[ Q /q � j a ❑ V !J AL:(:T.: I, as owner of the property, or my employees with wages '11'S as their sole compensation, will do the work and the CITU PCC �. TEL.N Q ,-0L „If7 6It A, structure is not intended or offered for sale (Section 7044, OWNER l• _ JJ 1 ITEi� Business and Professions Code). M ❑ I, as owner Of the properly, am exclusively contracting MAIL TI.ITAL63 - 00 with licensed contractors to construct the project (Sec- ADDRESS 19�l7✓C. tion 7044, Business and Professions Code). C.'HECK 63,011 CONSTRUCTION LENDING AGENCY CITU TEL.NO. ,1l�_ hereby affirm that there is a construction lending agency for D f-RANGE" '1j1I the performance of the work for which this permit Is issued CONTRACTOR C—L (Sec. 3097,Civ.C.). Lender's Name ADDRESS fftjlfl-fl(Illi 211%27/91 CITY TEL.NO. Lender's Address -*Z 1 A l E 3a I certify that I have read this application and state that the above LICENSE NO.TATE CLCASS 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 prrooRgrtrttom/y for mspegtion pur oosesyq SEE REVERSE FOR EXPLANATORY LANGUAGE e NAT -ATFL LA� OR AGEN�1' -IE ` WORKERS!COMPENSATION DECLARATION P' P ILVCi'YMN FOR PIGIKMT •.10--herekyyaffkot4hat I hone a certificate of conseri self insure;or a cerrficate of Workers'Compensation Insurance, 76A364C HEATING - VENTILATING - AIR CONDITIONING oda certified copy thereof (Sec. 3800, Lab. C. CE-818(REV. 10/81) •Policy NCompany Certirtified 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 910 T• & W tion department. - (PRINT OR TYPE ONLY) ADDRESS /fI b Lr Date Applicant LOCALITY lL.CIAQL�6- NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST COMPENSATION INSURANCE CROSS ST. G��• / V Ci DISTRIcr NO. (This section need not be completed if the work InvABSORPTION UNIT, BTU PROCESSED BY Involved by I / the permit is for one hundred dollars e wow or less.)hi AIR HANDLING UNIT, CFM f/i1 oy 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 become subject to the Workers�pn Laws. BOILER, BTU APPROVALS DATE NSPE OR IGNAru Date Applicant COMPRESSOR, BTU 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 VALIDATION with comply with rovism 1 ort "Part Shia be . deemed revoked. FURNACE: FAU_GRAVITY I LICENSENO TRACTORS DEC A ATIO VL�� FLOOR BTU �f! I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDEDLUNIi_ /1 0 HEATER: WALL (/ l% '(commencing with Section 7000) of Division 3 of the Business E> and Professions Code,and my license is in full force and effect. �ry �af 7 iJ r License Number Lic. Class ;20041A OU odFt EHaNuf RtfIC A9oeov D W. . . . . 8 0 ❑Contractor Date " L. C-T1R_c� O_ A !DL � •I e,. 2 0.5 0 y I am exempt under Sec 7 ( /l iY'FLFVrGr triW 91. B.BP.C. for this reason' PCO checkfee •.'.'. `2 Q 5 0 9 N PERMIT ISSUING FEE $ S z Date: 0629-88 Signature TOTAL FEE S OWNER-BUILDER DECLARAJTION PLAN CHECK APPLICANT I hereby affirm that I am exempt from the Contractor's License t An, D Law for the following reason (Section 7031.5, Business and NAME i7llif �7�f�, ��y Professions Code): ' tQp 1&AA� yAI I, as owner of the property, or my employees with ADDRESS -{Qp l wages ct their sole compensation, will f o the work and CITY P TEL NO. �p F 7 the structure is not intended or offered for sale(Section �� (�� (//a.1 � 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. 1 hereby affirm that there is a construction lending agency for D the performance of the work for which this permit is issued CONTRACTOR (Sec. 3097, Ci, C.). ADDRESS u. Lender's Name , J CITY TEL. NO. Lender's Address - STATE LIC. I certify that I have read this application and state that the LICENSE NO. CLASS above information is correct. agree to comply wish all County ordinancesesan and State lows relating to building construction, and hereby authorize representatives of this County to enter upon the above-mentioned property for ins ect n purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE 3 s1 �� Signa N"e of Applicant or Agent Date