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HomeMy Public PortalAbout9614 BROADWAY_Mechanical__ WORKERS COMPENSATION DECLARATION 20-0046 DPW 9189 Li■-■E GREEN I hereby affirm that-I have a certificate of consent to self insure, 76A364C APPLICATION FOR PERMIT , or a certiticaterol Worker's Compensation Insurance, or a certified HEATING -VENTILATING -AIR CONDITIONING copy thereof(Sec. 3380000 Lab. C.) " Policy'No._ncpy �Company "�u�/�� �iV/>GM'//��Y ❑ COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV. Certified copy is hereby furnished, Certified co Is filed with the count bu'ldin In action FOR APPLICANT TO FILL IN BUILDING depart Py ,r�( g p (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 DISTRICT 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 RPPFWALS DATE INSPECTOR'S SIG TUFE 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 /U provisions of the Labor Code, you must forthwith comply with such FINAL _ 4� provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATION r' I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT— 37.03 5r}. 5 (commencing with Section 7000) of Division 3 of the Business and HEATER: WALL - Professions Code, and my license is in full force and effect. _/ ` ( 1 ITEMS. '7 TOTAL 54 . 75 License Number / Lia Class 0 D yTZ-A�_ 5 p CHECK :4.75} Contractor "'L//// Date CHANGE .Orr p ❑ I am exempt under Sec. Plan Check fee _ - _ V Q B.&P.C.for this reason PERMIT ISSUING FEE t�-1/01)I]O�-QIjU2 vf 'Y.'�`_0 Date: TOTAL FEE 5 1413 1 AM 9:14 w Signature PLAN CHECK APPLICANT V (n OWNER-BUILDER DECLARATION Z I hereby affirm that I am exempt from the Contractor's License Law NAME , for the following reason (Section 7031.5, Business and Professions Code): 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, o ii cc Business and Professions Code). OWNER ❑ I, as owner of the property, am exclusively contracting MAIL n '- with licensed contractors to construct the project (Sec- ADDRESS y�j/G •-(J v�11J - tion 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY CITY f—x,,112 �r/rte TEL.NO. I hereby affirm that there is a construction lending agency for CONTRACTOR the performance of the work for which this permit Rs issued /✓K Y�jf/T //'T�. v - - _, (Sec. 3097,Civ. C.). / Z ►' - •t - ADDRESS / J 5a _ G�i� TLl Lender's Name ' CITY �wL TEL.NO. Lender's Address STATE LIC. v 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 insp 8, tion purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE - SI NATURE of APPLIC6NT OR AGS �� - ' 1'S COMPENSATION DECLARATION 20-0046 DPW 9/69 APPLICATION FOR PERMIT LIME GREEN hereby^ • :I have a certificate of consent to self insure, 76A360C or a ce;G�UNate of orker's Compensation Insurance, or a certified - HEATING-VENTILATING;AIR CG�'VDITKAING copy thereof(Seo,3800 Lab. C.) Policy Nd. PC943677 company Republic Indemnity COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV. ©.r_1 Certified copy is herebk59URANCE Cedified copy is filed wcoon FOR APPLICANT TO FILL IN BUILDING department. (PRINT OR TYPE ONLY) - ADDRESS 9614 Broadway Date 6/25/93 ApLOCALITY Temple Cit NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE'OF EM WORKERS' NEAREST CROSS ST. COMPENRANCE ABSORPTION UNIT,BTU SSOR (This section need not be cthe work in olved by the MAPASSEBOOK PAGEpermit is for one hundred dor less.) AIR HANDLING UNIT,CFM DISTRICT 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 p become subject to the Workers' Compensation Laws. �p 1 COMPRESSOR,BTU 24r000btu - APPROVALS GATE INSPECTOR'S SIGNATURE Date Applicant VENTILATION SYSTEM NOTICE TO APPLICANT: If, after making this Certificate of BOUGH Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLERp 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 1 FLOOR BTU VALIDATION 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 Professions Code, and my license is in full force and effect. License,Number 1 Lia C BE C-20 793 _ a Cont ctor ate _ Plan check fee under Sea 'AC4T.e V B.&P.C.for IN reason PERMIT ISSUING FEE$ '�� i ITEMS o Date: TOTAL FEE ' TOTAL 75. 45 45 a Signature PLAN CHECK APPLICANT OWNER-BUILDER DECLARATION 76' -- . --'- CHECK 75.45. Z I hereby affirm that I am exempt from the Contractor's License Law NAME - CHANGE - .013 for the following reason (Section 7031.5, Business and Professions ' ' HE Code): ADDRESS I, as owner of the property, or my employees with wages n t as their sole compensation, will do the work and'the CITY TEL..NO. CIoOCI-OUu1 6/25/57 structure is not intended or offered for sale (Section 7044, Business and Professions Code). OWNER Mr. & Mrs. Ronald Kline - 13474 1 AM104 6 ❑ I, as owner of the property, am exclusively contracting MAIL with licensed contractors to construct the pioject (Sec- ADDRESS 9614 Broadway tion 7044, Business and Professions Code). - CONSTRUCTION LENDING AGENCY CITY Temple City TEL No. 309_9111 1 hereby affirm that there is a construction lending agency for CONTRACTOR , the performance of the work for which this permit Is Issues Bryant Heating & A/C Inc. , (Sec.3097,Civ. C.). ADDIESS 1350 East Las Tunas Drive Lender's Name _ CITY San Gabriel TEL'ND' 286-1141 Lender's Address I certify that I have read this plication and state that the above LICENSE No. 221751 CLASS C-20 - Information is act. I a e comply with all County ordinances . and State s rel o uIng constructi ,and h by authorize represen lives th' ty to enter u n t ove-mentioned property for i s SEE REVERSE FOR EXPLANATORY LANGUAGE 6/25/93 SIGNATORAPPLICANT OR AGENT DATE