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Home My Public Portal About9437, 9441 , 9445 BROADWAY_Mechanical__ "WORKF.RS'COMPENSATION DECLARATION 78A364C APPLICATION FOR PERMIT 1 hereby affirm ihat I have a certificate of consent to self CE 678 12801 /9 r f /'9 I tl r fC r G f'C IVC 1 insure. or a certificate ofWorkers'Compensation insurance,of HEATING-V ENTILATI NG-AIR CONDITIONING a certified copy thereof(Sec.3800, Lab.C.) Policy NoBP.10314A—Company_CA1if._IDd._Ins.— ❑ Certified Copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY Certified copy is filed with the county;building inspection .FOR APPLICANT TO FI LL.IN BUILDING department. ADDRESS Date_4-17=B9—.Applicant_NIS_Mechanica1_SyStem- (PRINT OR TYPE ONLY) 9441-Broadway Jample-G].ty LOCALITY, CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE COMPENSATION INSURANCE NEAREST } (This Section neednot be completed if the work Involved ABSORPTION UNIT, BTU CROSS ST. It. by the permit is for one hundred dollars ($100) or less.) DISTRICT NO, PROCESSED By L) I certify that in the performance of the.work for which this AIR HANDLING UNIT,CFM Q W permit is'issued:1 shall not employ any person in any manner �' b O so as to become subject to the Workers' Compensation Laws. BOILER, BTU APPROVALS DATE 1NSPEC OR'S SIGNATURE W Date - Applicant 1 COMPRESSOR,BTU' 10.00 ROUGH r y NOTICE,TO APPLICANT: If..after making this Certificate of VENTILATION SYSTEMO Z Exemption, you should become subject to the Workers' FINAL Compensation provisions of the Labor Code, you must forth• with 'comply with such provisions or this permit shall be EVAPORATIVE COOLER VALIDATION deemed revoked. FURNACE: FAUX_ GRAVITY— LICENSED CONTRACTORS DECLAP ATION RAVITY_LICENSEDCONTRACTORSDECLARATION 1 FLOOR: BTU75,000 10:00 I hereby affirm that 1 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. 12 Supplys 21.00 License Number-550156— Lia Class (._20 ContractotNFS MzchaniCal Systers EXP 11-91 1 Return 1.75 Elam 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 $ �•� Lie.or Reg.No. Date - TOTAL FEE 53j25 HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT I hereby affirm that i am exempt from- the Contractor's NAME License Law for the.following.reason (Section 7031.5. Busi- ness and Professions Code): - ADDRESSi;!"T as ❑ 1, as owner of the property, will do the work and the CITY TEL.NO. ." 53.25 structure is not intended or offered for sale (Section 7044, Business and Professions Code). ❑ OWNER 'Brl�dWd Hares Looted Ltd. _ :I 1, as owner of the property, am exclusively contracting, y _ .with licensed contractors to construct the project MAIL 150 N. Santa Anita Ave. # 470 _ �1-1' �- 53 m ? (Section 7044, Business and Professions.Code). ADDRESS I. , , , = s. 1�a_, Jv.2.t CONSTRUCTION LENDING AGENCY CITY ArcadiaTEL.NO. - q� I heresy affirm that there is.a construction lending agency �'�•�'"+� '!�1 for the performance of"the work for which this permit is CONTRACTOR N E.S.'M2ChaillCal Systems issued (Sec.3097.Civ.C.). Lender's Name ADDRESS 518 S. Veriront Ave Lender's Address CITYTEL.NO. - - - Glendora Ca 91740 914-5696 '" 1 AN 9: 3 I certify, that 1 have read this 'application and state that the STATE 5501 LIC. C above information is correct.I agree Co comptY with all County LICENSE NO. - CLASS - - ordinunces and State haws 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 - tus>ection purposes. �J _ SignatureSignature oDate T-28— WORICEKS'COMPENSATION DECLARATION 76A364C ppp�I� ptIOp1 • COp pC.ppnly 1 hereby :ffirm that I have a' Certificate of consent to self CE-818 (2.80) P11'- 1- A 1 V 1- R PERMIT R M 1 insure, acertieeoof Workers'Compensation Insurance,of HEATING-VENTILATING-AIR CONDITIONING 'a certifice'3 copy thereof(Sec. 3800,Lab.CJ Policy No. EP10314A Company Calif. Ind. Ins. Certified espy iSherehy furnished. - - COUNTY OF LOS ANGELES . BUILDING AND SAFETY Certified copy is filed with the county building inspection FOR APPLICANT TO FILL_ IN BUILDING ' depYr[17 n' Date Applicant NM %ChanCal S yste15 '(PRINT OR TYPE ONLY) ADDRESS 9441BrOq _Te dyay, nple City ' , _ LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT - FEE COMPENSATION INSURANCE - NEAREST } (This section need not be completed if the work involved ABSORPTION UNIT, BTU CROSS ST. O by the permit' is for one hundred dollars, ($100) or less.) - DISTRICT NO. PROCESSED By L) I certify that in the performance of the.work for which this - AIR HANDLING UNIT,CFM tr permit is issued, 1 shall not employ any person in any manner O so as to become subject to the'Workers' Compensation Laws. BOILER, BTU _ - H APPROVALS DATINSPECTOR'S SIGNATURE ICI 'Date Applicant 1 COMPRESSOR, BTU 42,000 10.00 ROUGH �0�, 0. NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM s•-/f-v ? to Exemption, you should become subject to the Workers' FINAL � -L- Compensation provisions of the Labor Code, you mus[forth• - with comply with such provisions or this permit shall' be* _ EVAPORATIVE COOLER VALIDATION deemed revoked. - • FURNACE: FAUX GRAVITY_ 'LICENSED CONTRACTORS DECLARATION 1 FLOOR: BTU75,Q:Q10:00 I hereby affirm that I amlicensed 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. 12 Supply 21.00 License Number_550156_ Lic. Class_G_AJ • 1 :Reti1T'fl - 1175 Contractor-NFS_Mecha Gal_Systens EXP*11-_91 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 $ 10.50 Lic,or Reg.No. Date TOTAL FEE 5325 _ HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT I herebyaffirm that I am exempt from- the Contractor's NAME License Law for the following reason (Section. 7031.5. Busi- nessand Professions Code): - - ADDRESS 1, asowner of the property, will do the work and the B4 `V ' - .structure is not intended or offered for sale (Section CITY TEL. NO. 7-,F,i _Z c 7044, Business and Professions Code). _ _ .3`2 ❑ OWNER BrOadkH Hanes Lindted Ltd. " Z I Eh 1, as-owner of the.property, am exclusively contracting y I:- with licensed contractors to construct. the project _ MAIL 150 N. Santa Anita # 470 3t_i''AI 53 e 25 (Section 7044, Business and Professions Code). ADDRESS ArCadsa Ca.CITY. TEL.NO. (+ .-r•' .1=.iJ CONSTRUCTION LENDING AGENCY - 1 hereby performance there is a construction lending agency f'� .IJG for the 'performance of the work for which this permit is CONTRACTOR Ns NeCllaniCal' Systl3ns - Lend 's Name 7,c,y:c.). 518 S. Vermnt Ave. _ Lender's Name ADDRESS - Lender's Addressr - CITY TEL.NO. Glendora CA. 91740 914^5696 £"= } AN OP.14 �l certify thabl,have read this application and state that the1 STATE 550156 LIC. G �. above informution:is correct.I agree to comply with a11 County LICENSE NO. `CLASS ordinances and State laws regulating Heating. Ventilating and Air Conditioning,'and hereby authorize representatives of this SEF, REVERSE FOR EXPLANATORY LANGUAGE ' County to enter upon the above-mentioned' property for 'ire � tion purposes. Signature of Permittee Date - -