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Home My Public Portal About9665 BROADWAY_Mechanical__ •• ,WORKERS' COMPENSATION DECLARATION APPLICATION FOR PERMIT I hereby affirm that I hove a certificate of consent to self insure,.or o certificate of Workers'Compensation Insurance, - HEATING'- VENTILATING -'AIR CONDITIONING or a certified copy thereof (Sec. 3800, Lob:C.) 76A364C . s_. CE-818(REV. 10/81) - .. Policy No.—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 ( j- tion department. ADDRESS J(PRINT OR OR TYPE ONLY) _ L Date Applicant - LOCALITY - NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' " NEAREST COMPENSATION INSURANCE CROSS ST. (This section need not be completed if the work involved.by. ABSORPTION UNIT, BTU DISTRICT NO. PROCESSED BY the perrnit is for one hundred'dollors ($100)or less.) AIR HANDLING UNIT, CFM �f certify that in The performance of thework for which this permit is issued, I shall not employ an-person in any manner so as to become subject to the Work s Compensation Laws, BOILER, BTU APPROVALS DATE INSP T R'SSIGNATURE , Date Applica COMPRESSOR, BTU ROUGH L NOTICE 70 APPLICANT: If, a r 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 - VAL DATLO with'comply with such provisions or this permit shall be - deemed revoked. FURNACE FAU_GRAVITY - - LICENSED CONTRACTORS DECLARATION ". FLOOR BTU _ I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED—UNIT— (commencing USPENDED UNIT—(commencing with Section 7000) of Division 3 of the Business WALL and Professions Code,and my license is in full force and effect ' O� IL O License Number Lia Class - Contractor Date - 0- ❑ I am exempt under Sec. _ _ IM Plan check'fee - IL B.&P.C. for this reason' sit PERMIT ISSUING FEE $ Z N Date: Signature TOTAL FEE - _ e 0 7 4 5 A i is OWNER-BUILDER DECLARATION PLAN CHECKAPPLICANT #' 8 hereby affirm that I am exempt from the Contractor's License I • • 2 Q 5' aw for the fallowing reason (Section 7031.5, Business and NAMElalizo N D s e v 2 0,5 0 5 o essions Code): - J I, as owner of the property, or my employees with ADDRESS q L 92 2 -88 wages as their sole compensation, will do the work and CITV •Q.YF— • I` O the structure is not.intended or offered for sale(Section i TEL. NO. 11I 7044, Business and Professions Code). c ^ n OWNER „x=❑' 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 13yoaj W AGENCY CITY TEL NO C CONSTRUCTION LENDING AG "�- - - . . I hereby affirm that there is a constructions lending agency for D the performance of the work for which this permit is issued` CONTRACTOR - (Sec. 3097, Civ. C. "- - ADDRESS - ' Lender's Name T - I CITY. TE Lender's Address" STATE f certify that I hove read this application and state that the LICENSE NO. -CLASS above information is correct. I agree to comply with all County , ordinances and State laws relating to building construction, nd he �by uthorize•representatives of this County to enter - pon ve-mentioned property 4or inspection purpos ! SEE REVERSE FOR EXPLANATORY LANGUAGE - gna, of Applicant or or Agent Date WORKER'S COMPENSATION DECLARATION 26UO4C 9/99 APPLICATION FOR PERMIT LIME GREEN', 9A364C I hereby affirm that I pave a certificate of consent to self insure, [� or a certificale of Worker's Compensation Insurance, or a certified HEATING -VENTILATING-AIR CONDITIONING I I 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 - BUILDING department. (PRINT OR TYPE ONLY) ADDRESS Date Applicant LOCALITY ) NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST COMPENSATION INSURANCE CROSS ST. ABSORPTION UNIT,BTU �a (This section need not be completed i/the work Involved by the ASSESSOR MAP BOOK 8586 PAGE �d PARCEL permit is for one hundred dollars($100)or lase.) 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 iany manner so as to BOILER,BTU become subject to the Workers'Compensation Laws. / d COMPRESSOR,BTU GSD J �}y� J�df _ APPROVALS DATE INSP TOR'S SIGNANflE Date d q v Applicant t" VENTILATION SYSTEM / NOTICE O PPLICANT: If, after making this Cert ate 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 Q / VALIDATION . LICENSED CONTRACTORS DECLARATION - FLOOR BTU :J J 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 mylicenseis in full force and effect. / i 6 Yat 574 1 License Number _%0 ,01- Lic.Class Contractor W/Sr kxA-irlate q i .0 ❑ I am exempt under Sec. Plan check fee U B.&P.C.for this reason PERMIT ISSUING FEE $ _ a 0 Date: - - TOTAL FEE �' / -� W Signature -'_ ----y:_ ,- d -- - 1'v!_m , Fn OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT - Z_ 1 hereby affirm that I am exempt from the Contractor's License Law NAME ' = '� -^_ - �lldlLt7Arrrry GSr larli(�vg t_ .�_ for the following reason (Section 7031.5, Business and Professions _, Code): ADDRESS -- ❑ I, as owner of the property, Or my employees with wages "' ' .. } • ,1(_I as their sole compensation, will do the work and the CITY AhV TEL.NO. -f3V structure is not intended or offered.for sale (Section 7044, Business and Professions Code). OWNER - ❑ I, as owner of the property,.am exclusively contracting - - ice.` +_'.�' -1 vl-� 7/K MAIL' - c with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY CITY TEL.NO. - 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.NOUOef I3 - Lender's Address STATE , / p LID. I certify that I have read this application and state that the above LICENSE NO. � T � 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 props ty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE .. 7 z _ _ SIGNATURE OF APPLICANT OR AGEIT i ATE -