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HomeMy Public PortalAbout5017 CLOVERLY AVE_Mechanical__ ION WORKER'S I have a certificate of consent to 76A346DPW9/69 APPLICATION FOR PERMIT LIME GREEN 76A364C I here)ay of#irm that I have a certificate of consent to self insure, or a certificate of Worker's Compensation Insurance, or a certified HEATING -VENTILATING-AIR CONDITIONING copy thefojf(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 count buildingInspection FOR APPLICANT TO FILL IN BUILDING ``�� department. y (PRINT OR TYPE ONLY) ADDRESS V C ,1e],t \ 4UgF Date Applicant LOCALITY�� NO. TYPE OF APPLIANCE OR EQUIPMENT FEE G 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 ((yy permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM 0 �1� PAGE Oaf PARCEL' DISTRICT NO. PROCESSED BY I certify that in the,performance of the work for which this permit is issued, I shall not employ any person in any manner so as to BOILER,BTU r become su fect to t Workers' Compensation Laws. fi a � COMPRESSOR,BTU APPROVALS DATE INSPECTOR'S SIGNATURE Date L AppIicant �J VENTILATION SYSTEM NOTI E'TO P (CANT: If, aft aking this Certificate of ROUGH Exe ption, yo should become subject to the Workers'Compensation EVAPORATIVE COOLER prov sions of the Labor Code, you must forthwith comply with such FINAL j s provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY w LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATION '•_; _,': I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT i 3 (commencing with Section 7000) of Division 3 of the Business and WALL Professions Code,and my license is in full force and effect. License Number-4, g4o/ 9 Lic.Class Contractor T '�f�� Date c El Plan check fee I#J 1j_s'#-"_f4 'i ' . ,r, O I am exempt under Sec. 'tc B.&P.C.for this I PERMIT ISSUING FEE$ !7� `__!:0 1— Da TOTAL FEE . W Signature \ 11 V�41 ER-BUI E DECLARATION PLAN CHECK APPLICANT Cl) 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 ❑ 1, 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, 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. S I 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.). 14� — / ADDRESS,&2,----' Lender's Na — ,l'�../��.� L, 4 �`-� CITY TEL.NO. Lender's Address STATE T LIC. 6i J I certify that I/hnaveead this application and state that the above LICENSE NO. � CLASS information is . I agree to comply with all County ordinances and State sto Iding construction,and hereby authorize repre yi s Oou ty to enter upon the above-mentioned pr for tion rposes. SEE REVERSE FOR EXPLANATORY LANGUAGE �S GNATUR - PPLICA T O AGENT DAT ION DECLARATI AGR WORKER'S I have a certificate of consent to 76A346DPW9/89 APPLICATION FOR PERMIT IE EE " 76A364C I hereby affirm that I have a certificate of consent to self insure, or a certificate of Worker's Compensation Insurance, or a certified HEATING- VENTILATING -AIR CONDITIONING copy thereof(Sec.3800 Lab. C.) �vJ Policy No %'T_Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV. Certified copy is hereby furnished. ❑ Certified co Is filed with the count buildingInspection FOR APPLICANT TO FILL IN BUILDING department ( ) copy y PRINT OR TYPE ONLY ADDRESS I LOCALITY"'`:` Date Applicant 7 NO. TYPE OF APPLIANCE OR EQUIPMENT FEE 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 APPROVALS DATE INSPECTOR'S SIGNATURE Date 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 .h GRAVITY LICENSED CONTRACTORS DECLARATION h FLOOR BTU VALIDATION I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT (commencing with Section 7000) of Division 3 of the Business and WALL Professions Code,and my license is in full force and effect. License Number Lic.Class Contractor Date U ❑ I am exempt under Sec. Plan Check fee LU B.&P.C.for this reason PERMIT ISSUING FEE $ LL Date: TOTAL FEE Signature Q OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT a: O 1 hereby affirm that I am exempt from the Contractor's License Law NAME , CL for the following reason (Section 7031.5, Business and Professions Co e)' ADDRESS LU 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, 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 agecy for CONTRACTOR ► the performance of the work for which this permint is issued (Sec. 3097, Civ. C.). ADDRESS Lender's Name CITY TEL.NO. - q 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 t I SIGNATURE OF ARPLICANT.O'AGENT DATE WORKER'S COMPENSATION DECLARATION 20-0046 DPW 9/69 I hereby aSiirm that I have a certificate of consent to self insure, APPLICATION FOR PERMIT LIME LIME G oK a certificate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING copy thereof(Sec.3800 Lab.C.) id Policy No. Cdr any COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY, DIV. Certified copy is hereby furnished. ❑ FOR APPLICANT TO FILL IN BUILDING Certified copy is filed with the county buildi inspection (PRINT OR TYPE ONLY)' ADDRESS departmen LOCALI Date Appll NO. TYPE OF APPLIANCE OR EQUIPMENT FEE NEAREST CERTIFICATE OF EXEMPTION FROM JORZS1 CROSS ST. COMPENSATION INSURANCE ABSORPTION UNIT,BTU (This section need not be completed if the work involved by the ASSESSOR MAP BOOK ���/,� PAGE !10a" PARCEL��4 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 - J become subject to the Workers' Compensation Laws. 7^/f �� 22`aZJ COMPRESSOR,BTU / APPROVALS DATE INSPECTOR'S SIGNATURE Date Applicant VENTILATION SYSTEM NOTICE TO APPLICANT: If, after making this Certificate of ROUGH Exemption,you should become subject to the Workers' CompensationEVAPORATIVE COOLER provisions of the Labor Code, you must forthwith comply with such VFINAL provisions or this"permit shall be deemed revoked. FURNACE: FAU GRAVTYV V'-'('DATION 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 and WALL Professions Code,and my license is in full force and effect. License Number Lic.Class V CL Contractor Date r-1 X, O i'i'•: Plan.check fee _ \O I am exempt under Sec. 4 SI. 37n 713 O B.BP.C.for this reason PERMIT ISSUING FEE $ & S/Q I T I r M 0 Date: TOTAL FEE 0 TOTAL a 7m _d_7 0 d Signatureti:l CD OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT is ECK I hereby affirm that I am exempt from the Contractor's License Law NAME , CHANGE o('I' for the following reason (Section 7031.5, Business and Professions Code): ADDRESS ❑ I, as owner of the property, or my employees with wages r 0I'D!!_011 Iy +f - r as their sole compensation, will do the work and the CITY TEL.NO. structure is not intended or offered for sale (Section 7044, 17 Arti0;l1,1 Business and Professions Code). ILIWNER ❑ 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). - ��/77� CONSTRUCTION LENDING AGENCY CITY TE .NO�l1J� I hereby affirm that there is a construction lending agency for ONTRACTOR the performance of the work for which this permit Is issued (Sec.3097,Civ. C.). T ADDRESSC r �, � r Lender's Name ' CITY ` TEL.NO. _ 4 Lender's Address STATE LIC. I certify that I have read this application and state that the above LICENSE NO. (D0©$ CLASS C 19L<5 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 Q..E4cflon Puroses. SEE REVERSE FOR EXPLANATORY LANGUAGE AGENT D E