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Home My Public Portal About5828 BURTON AVE_Mechanical__ -WOR`ER'SCOMPENSxAT7C7M20-004 DECLARATION 20-D046 DPW 9/89 APPLICATION .FOR P1=RnflIT �� GREEN 20-D04PEA3"C I hereby affirm that I have a certificate of-consent to self insure, or a ceiniAcate o6 Worker's-CompensMion Insurbnce, or a.certified HEATING-VENTILATING -AIR CONDITIONING copy tftreof.(Sec.3800 tab. C.) - Po ficy 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 SUI E S department. (PRINT OR TYPE ONLY) Date Applicant LOCALITY - NO.. TYPE OF APPLIANCE OR EQUIPMENT FEE - - CERTIFICATE OF EXEMPTION.FROM WORKERS' NEAREST- - COMPENSATION INSURANCE CROSS ST.- 1. b ABSORPTION UNIT,BTUk a, - ASSESSOR -- (This section need not be completed($1 if the work involved by the MAP BOOK PAGE ° PARCEL permit i3 for one a performance antes($100)or less.) AIR HANDLING UNIT,CFM pISTRICT NO. PRocEssE v 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. ,7 � •V _ �•' Z COMPRESSOR,BTU 2O X - , '1 A APPROVALeOTTE INSPECTOn'S eIG Tb RE Date C , Applicant / VENTILATION SYSTEM �r� (,�,�,,,,� .� NOTICE T APPL CANT: If, after making this Certificate of - `v " ">' �2. ROUGH Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER provisions oL the Labor Code, you must forthwith comply with such FINAL provisions or this permit shall be deemed revoked. FURNACE: FAU_GRAVITY y- - r LICENSED CONTRACTORS DECLARATION,-, ` FLOOR . BTU J3 VALIDATION~ - 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 4586 3 Lic.Class I ` ' C��r7IvL'r.L'e� D Contractor C.W1`y 5 Aw— Date o ❑ U I am exempt under Sec. Plan check fee B.aP.C.for(his reason ' - PERMIT ISSUING FEES 2'1 3O - �- � � � U Date: TOTAL.FEE ZZq -'-�O d Signature .,. _` _ U OWNER- PLAN CHECK APPLICANT• _ _ , BUILDER DECLARATION Z I hereby affirm that)am exempt from the Contractor's License Law NAMEI D '. for the following reason'(Section 7031.5, Business and Professions - - ` T9 Code): ADDRESS - .. - .. r ' ❑ I, as owner of the property, or my employees with wages - 11t.f00-0001 10110/9` as their sole compensation, will do the work and the CITY TEL.NO. ( Il 8p,55 . structure is not ihtended or offered for sale (Section 7044; r'2fyVS r i 'Atl G Business and Professions Code). OWNER - ❑P. 1, as owner of the property, am exclusively contracting MAIL ,( IN ,LA • with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code). - 'CONSTRUCTION LENDINGAGENCY - - - CITY TEL.NO.. I affirm that there is aconstruction lending agency Tor CONTRACTOR 1 the performance of the work for. which this.permit Is issued (Sec.3097, Civ.C_). ADDRESS - ,Lender's Name CITY , 7 Lender's Address ' STATE 1 certify that I have read this application and•state that the aboveLICENSE NO. — CLASS information is correct. I agree to comply with all County ordinances and State laws relating to building construction,and hereby authorize - representativesof this County to enter upon the above-mentioned - property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE' '1 SIGNATURE UC:PLICANT OR AGENT WORKER'S COMPENSATION DECLARATION 90a0/6OPW9/e9 ,�� GREEN I hereby affirm'Ehat I have a certificate of consent to self insure, 76A364C APPLICATION FOR PERMIT , J = or a certificate of Worker's Compensation Insurance, or a certified HEATING - VENTILATING -AIR CONDITIONING copy thereof(Sec.3800 Lab. C.) Cl Policy No. Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV. ❑ Certified copy is hereby furnished. E] Certifiedcopy is filed with the county building Inspection FOR APPLICANT TO FILL IN ADDRESS department. (PRINT OR TYPE ONLY) Date ApplicantLOCALITY NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST CROSS COMPENSATION INSURANCE ABSORPTION UNIT,BTU ASSESSOR (This-section need not be completed If the work Involved by the permit Is for one hundred dollars($100)or lees.) MAP BOOK PAGE PARCEL AIR HANDLING UNIT,CFM oismlcr 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 APPPOVALS UATE INSPECTOR'S SIGNATURE Data Applicant VENTILATION SYSTEM NOTICE TO APPLICANT: If, after 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: FAU_GRAVITY LICENSED CONTRACTORS DECLARATION FLOOR BTU 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: WALL Professions Code, and my license is in full force and effect. License Number Lic.Class , } 0. Contractor Date V ❑ I am exempt under Sec. Plan check fee w J B.aP.c.for this reason PERMIT ISSUING FEES ILL Date: TOTAL FEE QQ Signature PLAN CHECK APPLICANT OWNER-BUILDER DECLARATION - 0 1 hereby affirm that I am exempt from the Contractor's License Lew NAMEd for the following reason (Section 7031.5, Business and Professions , )'t":° ' 2 Code): ADDRESS FW– I, as owner of the property, or my employees with wages as their sole compensation, will do the work and the Clry TEL.NO. structure is not intended or offered for sale (Section 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. I hereby affirm that there is a construction lending ag9ency for CONTRACTOR , the performance of the work for which this permit iissued (Secs.3097,Civ. C.). ADDRESS Lender's Name CITY TEL NO, Lender's Address STATE LIC. 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 inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE SIGNATURE OF APPLICANT Oa AGENT DATE