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HomeMy Public PortalAbout9325 BROADWAY_Mechanical__ WORKERS' COMPENSATION DECLARATION ,/ APPLICATION N PPLICATIOFOR PERMIT i hereby affirm that I have a certificate of.consPnt to self �y irture, or'o certificate of Workers' Compensation Insurance, HEATING VENTILATING - AIR CONDITIONING ,or d ertif dopy thereof (Sec. 3800, ab.C.) 76A364C �! 20-0046 DPW 9/88 Policy I?d(�Company ��r ❑ 'Certified copy is hereby turnishe .. COUNTY OF LOS ANGELES BUILDING AND SAFETY , , Certified copy'is filed with the county building inspec- - FOR APPLICANT TO FILL IN BUILDING �w'{,,� tion department. //� n•r{� - (PRINT OR TYPE ONLY) ADDRESS Date / / ,�O Applicant x•-r �! r J, Qfl T! LOCALITY /s NO. TYPE OF APPLIANCE OR EQUIPMENT FEE 7C, CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST y COMPENSATION INSURANCE CROSS ST. / ! (This seetion•nABSORPTION UNIT, BTU eed not be completed II the work involved by olsrRlcr No, ocEsseo By ' the permit Is for one hundred dollars ($100) or)ess.) �' r/ r I certify that in the performance of the work for which this AIR HANDLING UNIT, CFM VX permit is issued, I shall not employ any person in any manner so as to become subject to the Workers Compensation Laws. BOILER,BTU APPRovAtS DATE INSPEOOR's SIGNATURE Dale Applicant IT COMPRESSOR, BTU III Ja 0 ROUGH NOTICE TO APPLICANT: If„after making this Certificate of .. VENTILATION SYSTEM _ FINAL �- Exemption, you should' became subject to the.Workers' Compensation provisions of the Labor Code, you must forth- .EVAPORATIVE COOLER .VALIDATION ' with comply withiu2h provisions or this permit shall be deem- 'ed revoked. i FURNACE: FAU_GRAVITY _ LICENSED CONTRACTORS DECLARATION FLOOR BTU ' I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT_ ( t, WALLcommencing withsection 7000)of'Divislon 3�of the Business P and Professions Code,and my license-is in full force and effect. U Nelms J - I / > License NumberV373•S- Lic, Class pee?b e3g ' �✓pY2cjco Cont, Coa2Dr . .3p—actor a Ix '❑ I'arh exempt under Sec Plan check fee u B.BP:C. for this reason. to N Date: PERMIT ISSUING FEE.$ Z Signature TOTAL FEE OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT ' -. -1 hereby affirm thabl`a'm exempt from the Contractor's License D Law for the following reason (Section 7031.5, Business and NAME' - g Professions Code): - ❑ I, as owner of the property, or my employees with ADDRESS -- ACCT. • wages as their soe compensation,.will do the work and r the structure is not intended or offered for sale(Section CITY TEL NO. 33,07 20.`0 7044, Business and Professions Code). OWNER. 2 b L � - 1 ITEMS with as owner of the property, am exclusively contracting .with licensed contractors to construct the project (Sec- MAILTOTAL 20 .r?Q tion 7044, Business and Professions Code). ADDRESS _- CONSTRUCTION LENDING AGENCY CITY •7"'�s TEL. NO. �'.,/p�o CHECK 20.50 I hereby affirm that there is a construction lending agency for / /} /� the performance of the work for which this permit is issued CONTRACTOR CJoyND/L �%L Cd CHANGE (Sec. 3097, Civ. C.). - /✓� � D Lender's Name ' ADDRESS � N /U�lN! - Lender's Address CITY TP �e P, ¢ TEL. NO.� -3f S7 0000-0001 9/12/89 STATE t // 9 LIC. - 56T 1 AM 9:33 Icertify that have read this application and state that the LICENSE NO. TO J 735 CLASS SCD C�.p 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 , upyypggq the above-mentigggyypGGGd property for inspection purposes' SEE REVERSE FOR EXPLANATORY LANGUAGE Signature ofApplicant or Agent —7N Date / ©s C�oN/y0/t Alii C'o�v�P. WORKERS'COMPENSATION DECLARATION APPLICATION L PPL IC pP9 X TION FOR PERMIT ER�N� Y IT I hereby affirm that I have a certificate of consent to self P'i Ytl insure, or a certificate of Workers' Compensation Insurance, 7cri3t4C HEATING - VENTILATING - AIR CONDITIONING or a certified copy thereof (Sec. 3800, Lab. C.) CE-818(REV. ID/BI) Policy N -Company COUNTY OF LOS ANGELES `"' BUILDING AND SAFETY Certified ified copy is hereby furnished. 'I _ Certified copy is filed with the county building inspec- FOR APPLICANT-.TO FILL IN BUILDING ^ /,^�{ tion department. (PRINT OR TYPE ONLY) ADDRESS Os I✓IQ 4La Date Applicant - LOCALITY r� C NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' _ NEAREST COMPENSATION INSURANCE CROSS ST. !fill Ns fl (This section need not be completed If the work involved by ABSORPTION UNIT, BTU DISTRICT NO. PROCESSED BY the permit is for one hundred dollars ($100)or less.) - S. AIR HANDLING UNIT, CFM Q I certify That in the performance of the work for which this � permit is issued, I shall not employ any person in any manner BOILERBTU O O odd So as to become subject to the Workers'Co ,mpensalion laws. APPROVALS DAl INSPECTOR'S SIGNFTURF Date 3 4Io_8L Applicant / COMPRESSOR, BTU ROUGH 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 such provisions or this permit shall be deemed revoked. I FURNACE: .FAU_GRAVFY' LICENSED CONTRACTORS DECLARATION FLOOR BTU — I hereby affirm that I am licensed under provisions of Chapter 9SUSPENDED UNIT_ '(commencing with Section 7000) of Division 3 of the Business HEATER: WALL and Professions Code,and my license is in full force and effect. - y O License Number Lic. Class— Contractor lass Contractor Date - O 0 ❑ W am exempt under Sec. Plan check fee H 8.8P.C. for this reason' Z Date: PERMIT ISSUING FEES - /O Sd 3 Signature TOTAL FEE 01 - OWNER-BUILDER DEC,LARATION PLAN CHECK A UCANT I hereby affirm that I am exempt from the Contractor's License D Low for the following reason (Section 7031.5, Business and NAME Professions Code): - ❑ I, as owner of the property, or my employees with ADDRESS 20920A wages ct their sole compensation,will for the work and CITY TEL. NO. the structure is not intended or offered for sale (Section . o e o e • a 7044, Business and Professions Code). � - - I OWNER Tea N. ❑ I, as owner of the property, am exclusively contracting MAIL 2 • • 30.50 with licensed contractors to construct the project (Sec- ADDRESS 3 ps`7 r W 'oto'a x tion 7044, Business and Professions Code). —rt 3'O, rJ O a CONSTRUCTION LENDING.AGENCY CITY /G TEC'NO. . L I L I hereby affirm that there is a construction lending agency for - D O 5 0 2— 84 the performance of the work for which this permit is issuedCONTRACTOR (Sec. 3097, Civ. C.). - - - - ADDRESS - - - - - Lender's Name -"'^'•-' 'A CITY TEL..NO. .. . . _ Lender's Address STATE LIC, I certify that I have read this application and state that the pCENSE - 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 upo thea ave-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE /�,�7(./�y�,r►pp�1��' /d�ae.� 3 704 Signature of Applicant or Agent Date ' APPLICATION I� t4A76 P WORKERS'COMPENSATION DECLARATION CEA 8018 (2-80) A P Y'� L IC A 1 I Q 1 tl FOR PERMIT I herebv affirm that I have a' certificate of consent to self - insure, oracert7icateof'Workers'Compensation Insurance.or HEATING-VENTILATING-AIR CONDITIONING a ce�lified co­thereof(Sec. 3800, Lab.C.) Pz8 &oy / Policy h.,. Com pany_ZC`_'n..� h ' I� ❑ Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY LF""yCertified copy is filed with the county building inspection FOR APPLICANT TO FILL IN BUILDING Date.�I/�W Applicant o hb tie N—ZZKS f NC (PRINT OR TYPE ONLY) ADDRESS / ;� 5 •-� / 7,r0 G l` L.(�Cl j CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY ' e 1^^-� i Q—�` COMPENSATION INSURANCE NEAREST IC } (This section need not be completed If the Work involved ABSORPTION UNIT, BTU CROSS ST. eV C jVr' O by the permit is for one hundred dollars ($I00) Or less.) DISTRICT NO. PROCESSE^ev CJ 1 certify that in the performance of the work for which this AIR HANDLING UNIY,CFM �/ / permit is issued, I shall not employ any person in any manner 0- � Q so as to become subject to the Workers' Compensation Laws. BOILER,BTU J H APPROVALS DATE INSPECTOR'S SIGNATURE IU Date Applicant COMPRESSOR,BTU— ROUGH S -� ' fL NOTICE TO APPLICANT: If, after making this Certificate of 'VENTILATION SYSTEM FINAL .I L Z Exemption, you should become subject to, the Workers' Compensation provisions of the Labor Code, you must forth EVAPORATIVE COOLER with comply with such provisions or this permit shall be ./ VALI A ' deemed revoked. FURNACE: FAU_✓ GRAVITY . .LICENSED CONTRACTORS DECLARATION / FLOOR: BTU_/o_C�-/Y.t— I eieby affirm that I am licensed under provisions of Chapter HEATER: SUSPENDED UNIT (commencing with Section 7000)of Division 3 of the Busi- WALL ness and Professions Code. and my license is in full force and effect. �•z / ! �o - License Number./5 7b f 1),b Lic.Class. � �5 Conlractor.Q�f wPJS4le3�Iv este �l/�O�p�J ❑ I am exempt from the licensing requirements as 1 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 $ Lia or Reg.No. Date TOTAL FEED HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT 1 hereby affirm that 1 am exempt from- the Contractor's NAME License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): ADDRESS - - ❑ 1, as owner of the property, will do the work and the 227 2 5 4 A structure is not intended or offered for sale (Section CITY TEL. NO. 7044, Business and Professions Code). - .e.e • e'o 8 —1^ 1, ' ❑ I, as owner of the properly, am exclusively OWNER �contracting l �1 Q'r-A 2 Q 5 O with licensed contractors to construct the project MAIL ,� II � • ` (Section 7044, Business and Professions Code). ADDRESS �� S �'• hd Q.v L1.1 A. VIIp,e"^ 2 Q 5,O 6 CITY TEL.NO.;Z `'D O 'S 3 CONSTRUCTION LENDING AGENCY ¢ C . .Z 1 2 1 I hereby affirm that [here is a construction lending agency - for the performance of the work for which this permlt is CONTRACTOR / p issued(Sec. 3097,Civ.C.). Lender's Name ADORESS,? YeoM Lender's Address 'lCITY f?a TEL. NO1 certify that I have read this apVlicalion and state that the STATE1 / LC.above information is correct. 1 agree to comply with all County LICENSE NO. . S V CLA '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-menti ed property for pu inspection re ses. 3a%— Signature of Permittee Dr.e