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HomeMy Public PortalAbout5333 & 5337 CAMELLIA AVE_Mechanical__ WORKERS'COMPFNSATION DECLARATION 76A364C -APPLICATION q P P L IC AT p O 1 FO PPERM 7" I hereby. attirm that I hove rt certlflcatb of tenant to self CE-818(2-n) - 7�.J I V r I!" IVtl II lntdure, or a cettifitata of Workers'Compeusntlon Iruirrance,of HEATING-VENTILATING- JR GONDMONtNG _ r ■cartlfled co y theroof' c. 800,Lah. C- f C.JJJI Polf-cy No� Parly i csr `r►,t)/ojC,�S c { �. COUNTY OF LOS ANGELES -g UILQING AND SA FF TY_� Certified ropy b hereby furnlshbd. . • - ,•. . Cettlflod eppX is filed with the c6trn y building Incpe-ctlop artment, FOR APPL[CANT'fi0 SILL IN. $Wl-D]Nc� Due lE 4�AfC (PAINT OR TYPEODRI °w$ App41.nI-E-/�tF11U /�l!�• 'ONLY) • - i CYRIIpiCATEOF•E�CEMPTiON FROM WQR£ 9' NO, TYPE OF APPLIANCE ORL-QUIPIIENT FEE t oGAtlr�r • 7 COMYRNSATfQN-INSUP-AigCE N�rAAI 3T edeti6n need `not b8 cosnp1et�ed -if the work.inv&"d ABRQRPIT IO-N,LyNht, BTU CROSS . by .the pelrmit fs for one huiidiid dollars ($100) or lead.) DI#PWT NO. a aK .8 ' I eoF#lfy Oar lrt the �vrforrnarrce.of tha wnzyc for yvhI0 tt la A1I3 AND lNp UN17 Ffvi r �`/ d � � permit is lzsubd.I thglltlot en4plby any person fn'any inn er C.! to esrta,bacpma subjdct to Rha'Workers'Compensttinn Ltwe- e IL BYU 'O. r �o APPROVALS D'AT6 �ecToaaaltz�ruFlE'. .'Nte. A.pplica CO R1 SSOA &Til Y' ROUS3H- . NOTICE TO APPLICANT: It; after duakihk this Certifldrte of° VEN.T(LATION S`G.9TEk4 ' F�NAI_ r Z' 'kxaioptlon: you should becornb' subject to the Werkert' _ Cpmpensatlon prods O4 df'the Lqbbr Code, you must forth- " _EVAFDOHAT1VE�CQOLER- VADDATION rvitU aolnpl yvitlr such •Provbfogs or.rihll.permit shall ba `-•._ - deemCdTaVO d. FURNACE-- •FAIL &RAVIT p : i LICEN$E-DCOrf R-ACTORS,DECLAP ATION ,' FLOOR., Tu I herehy tfftrm that I ani Ticdfmad under provisions of Cha 11, HEATER: SUSP€NDEO. , - UNIT' 9 (0rf1menchig,with Section'7000) of Dtv_bhe 3 of fhe Fast- NJAL1 r negt and rrofax4lent Code, and my-Ilcensa Is•in fuU fbrca apo' , Licaneh Numb�erv, � �ntrlCMfYrti.'""'!"F/�i i�at-0,. !'��.Q�pal I ` •�, -. ' _ f' '' r • 0 I am exempt from the if ansing reg0traments as I am a licensed architect•or a regirte, profeeeional enslnear Plan CheCkfe9'26`S Df Blwve. r t ,acting in my•'prorwignsl tapscity ($ecttQn 7051, Ous tndsa and Professions Code). PEF1M T JSSUINQ F`EE $ � } LIC,.or Rei.No.- Date r ; . - .7QTA1 PfQ•'. r .1io?4 OWNER-13w Dh'�DTCI ARA ETON P-LA CAECtK 5PPLI ANT ,l h"by ari'Urm tba-t I-tm exempt (Nm-ttki.GQntrn{oil4 NAME { 'r T• Y ` Ucehlb Lpw for'the Rilltpo-Sng reason,(r ectlon 7031.5, 'Buff- , - nbae et�d Profegdons i4odtr): : .. '. A-DDRESS' y i,.0 $sorter t{f the prbperty, vtg7 do the work ijW the - ; kt'ructure is Dot,Intended or offered for rile (Saetiop C�fTY T6L. NO. ; Q*t7 A Yt* ns e _ 7 4 meas Profbaafo d Iraq oNtier of the property, aur excluafvely torltn[xtn'g with I�mnsed Conttectdr► to construct the project-•. MAIL • h (Snctjon 7444, Eusinessand PpQfeaslorts.Code�. _ ADD r/+' Q •.• 2 ,J�d' t}OrI$TIlUC'JION LENDING AQENCY GUT1 t �' TEL.Nb. �_ io•Ja{af� rJpS l hereby affIm That tbere Us s, construction lending agency s for 'the pesformaneL* of.the-wo;k for.which this penitis 4 CONTRACTOR r� Issued(Set. 3097,Civ.C) Lender Name ADDRESS � Lender's Atidrosa CITY 6 TEL.NO. I certify that,l have'read thla application and state thatlthe' STATE LIC. above Information B correct.j•o�ree to comply with all County 3�• Z L CLASS• �~ ordlnanbes end• St'a I>Nw regulatlne Hegting, Ventilating rind Air Conditioning,and hereby authorize representettvas of ithls SF,); "VERSE_PQR EXPL,ANATQjtY-I XNGUAGE County to enter upon the abov.�-mentloned property.for hispectl n par ; ^ ore of ftrmittef Dtte WORKERS'COMPENSATION OECLARAI+bN T + 76A1364C I hereby affirm,the t I hrte a certificate.of consent'to self CE-818 (2-80) APPLICATION FOR PERMIT, irtrure,'or ■ certlficaWofworker# Cornpenaytloninsur■nce,oT HEATING-VENTILATING-AIR GONDITIONINd, ■cartlfled copy there5tf(Sec.3800,71_ab,C.) ; Peucy —Company OS ANGELES. BUILDING AND SAFETY Certirti fied copy JgYereb7 furnlahed. COUNTY OF L . . -- r ' Certifled cony itvMed with the county,6111dingi "eflon BUILDING '' department. FOR APPLICANT TO,F[L-L IN ' Date AVilcant ^ (PRINT OR.TYPE� ONLY) ADDRESS2 Axe, CERTIFICA`fE C)F EXEMPTION FROM WORKERS' • NO. . TYPE-OF APPLIANCE Oil E(]LJ1PMEN] FEE l-OFAL ITY COMPiNSATION[INSURANCE NEAREST ' (This Mcdon Aee+d vt C�ap�t ed if the.-v*Ork Judo�ved ABSORFYION UNIT,'BT CROSS-ST. by the.permit is fo one h4ndrdd ddDan (311)6) or AOM). 04"1 CT N0. ar L I cprtVy that io th6 perfotmance of the work for which this s AIR Fj4NDtING UNIT CFM pftVilt b issued, 1 mhd not enlpl4y sn�,7M h 1p nh7 ucna� so a116 become sub,ltot to the Workiiis Con'jpt7n%adopt= ws. 001 LE P,BTU APPROVALS DATE INVIECTOR SIGNATURE , -gate Applicant. _, COMPRE O RTU ' NOTkCE TQ APPLICANT`: If,afte�.makiil(l t�tia >fi�atd•or RouGH VE_aTILATfON SYSTEM� Z ExepYptitln, you sha4d become sub)eet 'to the .W(mkan' ~" FINAL Compensation provistons of the Lal}or.Godo-, you mutt forth- with comply•with'aech provisions or this permit-ahall•be EVAPORATLVE'C6dLEFf YauoAYroN deemed revoked - W EN98D G9SNtRAc-roRD£CLARATtON FLOOR: FAU GRA�/1TY I fi"by affirm thst-]am lieented under provi4orta OrC 4ptbi- HEATER: BUSPENDEQ- 1Jf4IY.; - �• r 9 (COMment:ingwith 3ection'7000) of Dtvfsion 3 of the-13LW- WALL ` nest and,ProfeWoga Code, and py licence is in full-ferca:and t effect. - - f . i.lcense Number- i.ic.Clam- Contractor 4 bath ,u 1-am,oAoM,pt i6m the llae�uin� roqulupibnts 6 I ttm a f iIcensed archltbct or a'ro#rMted profefttonat •enriqeer . P7an�ghgc %a 26%E)f'ab-dvia acttn4lit my profe"toril capacity (Section 7Q51,'$u; tneu and Proielstbw Cede) PERMIT ISSU4NG FEE$ IAC,or Rek.No. h Hate _ TOTAL FErf s - Pi01()i OWIVEIt-)jUILD$P'DEGLARATION. PLAN ckECK APPLI-CANT' _ I hmeky gffh= flint I -ahs bxerppt from- the.Contractor's' I NAMU. JaiheB -J.--CheValf@ LiconW.Law for the follpwinl reason (SectUon 7037.5, Busi- n6H and Profesgignr Code): ADgpl?S5,,- L a,owner of t¢e property, cul do Aha'wdrk and tbo t ttnrcture.Is not ldtended.or offered sate (Section CITY 7EL. N0: —85 Lb 7044rBysih*=and.Profeaslob Code). OWIJ6q _ (Y s gwner of the property, ani •xclusfvaly contAi tisk 3 1J,( h lieettsed. contractors t¢.eonstruet, the: -pro)-t MAIL' = y )o 7044, Bustneas and Proirawd9ns Code). ADDFtESS # •Y�•I i 4 1 C1T1C YEL. NO,_ ) ,1'�a© % C4NSTltUrr`TiON LENDING,AGP�ICY. 1 t — '2� •.y affirm that tho" L a•construction lending_agancy - . . " ' , 'performance of the wprk for Which this permft Is CONTRACTOR QQ°�Sec,B097rC1v.C.)., .t'Nerpe ADDPiE$8 s AddrbsaCITV. TEL.N4•y that I have read:this appllcatiodand state that theSTATEto_tion is covert.I agree_to comply wtth all County. tAS9 ces and State, laws regWetins Heating, Vontilating and dltloning, and hereby authorize representettves Vf.thia •SEE RBVERSE BOR EXPLANATORYLANGUAGE ,to enter upon •toe above dtentloned property for on pus