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HomeMy Public PortalAbout5022 CLOVERLY AVE_Mechanical__ ERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT I herE at I have a certificate of consent to self insure,, y ate of Workers' Compensation Insurance, 76A364C HEATING-- VENTILATING - AIR CONDITIONING or a c ied copy thereof (Sec. 3800, Lab. C.) CE-818(REV. 10/81) Policy No. Company Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY ❑ Certified copy isfiled with the county building inspec- FOR APPLICANT TO FILL IN BUILDING tion department. (PRINT OR TYPE ONLY) ADDRESS, O a Clove_v4v Ave Date Applicant LOCALITY ,d. q f 7S:b CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST NO. TYPE OF APPLIANCE OR EQUIPMENT FEE /`T l COMPENSATION INSURANCE CROSS ST. 0� ABSORPTION UNIT, BTU DISTRICT NO. PROCES (This section need not be completed if the work involved by the permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT, CFM rf O� 1 I certify that in the performance of the work for which this J permit is issued, I shall not employ any person in any manner so as to become subject to the Workers'Compensation Lov BOILER, BTU APPROVALS DATE INSPECTOR'S SIG TURE 41 Q COMPRESSOR, BTU ROUGH Date—941 Applicant NOTICE TO AP LICANT: If, after making this Ce—rtifixcaWte of VENTILATION SYSTEM FINAL Exemption, ,you should becomesubject to the Workers' Compensation provisions-of the Labor Code, you must forth- EVAPORATIVE COOLER VAI InAdION 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 SUSPENDED UNIT (commencing with Section 7000) of Division 3 of the Business HEATER: WALL and Professions Code,and my license is in full force and effect. 4 i O License Number Lic. Class I PF , Contractor Date I am exempt under Sec. as Plan check fee CL B.&P.C. for this reason' Date: PERMIT ISSUING FEE $ /O Signature TOTAL FEE 0 OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT I hereby affirm that I am exempt from the Contractor's License ► Law for the following reason (Section 7031.5, Business and NAME Professions Code): ❑ I, as owner of the property, or my employees with ADDRESS wages as their sole compensation, will do the work and CITY TEL. NO. the structure is not intended or offered for sale(Section 20 6 5 A 7044, Business and Professions Code). �--_ OWNER ,N I, as owner of the property, am exclusively contracting r << °o °o t- ADDRESSAV22 with licensed contractors to construct the project (Sec- j/C Q 9, � U tion 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY CITY '. TEL. N p I hereby.affirm that there is a construction lending agency for 9 b the performance of the work for which this permit is issued CONTRACTOR ► U�� (Sec. 3097, Civ. C.). Q U ADDRESS Lender's Name CITY TEL. NO. Lender's Address STATE LIC. I certify that I have 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, and hereby authorize representatives of this County to enter upon the above-menti ned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Sign Lure of Applicant or Agent Date ION DECLARAT WORKER'S I have a certificate of consent to zo_OG46DPW 9,f39 APPLICATION FOR PERMIT LIME GREEN 76A364C I he, affirm that I have a certificate of consent to self insure, or a certificate'of Worker's Compensation Insurance, or a certified HE -VENTILATING-AIR CONDITIONING copy 3hereof(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. C O✓ 2 i � department. (PRINT OR TYPE ONLY) ADDRESS L L Date Applicant LOCALITY f /I C a / old NO. TYPE OF APPLIANCE OR EQUIPMENT FEE /t O Lo aT CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST CROSS ST. Lr COMPENSATION INSURANCE ABSORPTION UNIT,BTU (This section need not be completed if the work involved by the ASSESSOR permit is for One hundred dollars($100)or less.) AIR HANDLING UNIT,CFM DISTRICT OOK PROCESSED BY PARCEL I certify that in the performance of the workfor which this permit is issued, I shall not employ any person in any manner so as to BOILER,BTU become subject tot Workers' Compensation Laws. ..�' / COMPRESSOR,BTU � APPROVALS DATE INSPECTOR'S SIGNATURE Date �TPpI icant VENTILATION SYSTEM - NOTICE O AP LI Nf, after making th s ertificate ROUGH Exemption,you should become•subject to the Wor rs'Compensa EVAPORATIVE COOLER ® p provisions of the Labor Code, you must forthwith comply with such FINAL provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY / LICENSED CONTRACTORS DECLARATION FLOOR BTU /� VALIDATION I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED NIT (commencing with Section 7000) of Division 3 of the Business and HEATER: WALL Professions Code,and my license is in full force and effect. 'Q2t,nse Number 7 • / C� Lia Class l�© r actor Q ❑ / 3/ e U I am exempt un Sea Plan check fecc B.&P.C.for this reason PERMIT ISSUING FEE$ 3 Date: TOTAL FEE 00W Signature d OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT 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): i'_•`_•t s ADDRESS❑ I, as owner of the property,.or myemployees with wages ` _Lk.Ic 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). y _ CONSTRUCTION'LENDING AGENCY CITY TEL.NO. I Lf is I hereby affirm that there is a construction lending agency for .rs+_INi: , � the performance of the work for which this permit Is issued CONTRACTOR„ (Sec.3097, Civ.C.). . ADDRESS Vr t/' €•`1`: Lender's Name QQ pa= "j`�e CITY &ALP W1*N PFT ttCTEL.NO. Lender's Address STATE o LIC. O ! w ,-; _ certify that I have read this application and.state that the above. LICENSE NO. g Q �j 3 CLASS '—�� j E_!1's^)�S_(�,y ,' C.'+_0 information is correct. I agree to comply with all County ordinances ^ and State laws relating to building construction,and hereby authorize t(-```= A I -'4 representatives of this County to enter upon the above-mentio ed property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE SIGNATURE OF APP NT OR AGENT M D E �