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Home My Public Portal About6033 CLOVERLY AVE_Mechanical__ iceWORKERS COMPENSATION DECLARATION IlI APPLICATION FOR PERMIT here- ,affirmrthat I have a certificate of consent to self Insure, ora certificate of Workers Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING or a certified copy thereof (Sec '3800, Lab C ) 76A364C - 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 tion department (PRINT OR TYPE ONLY) ADDRESS U tv- Date Applicant LOCALITY 4 ` 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 the permit is for one hundred dollars ($100)or less ) ' AIR HANDLING UNIT CFM I certify that in the performance of the work for which this permit Is Issued, I shall not employ any person In any manner BOILER BTU so as to become subject to the Workers'Compensation Laws APPROVALS DATE IN ECTOR S SIGNATURE Date Applicant ST 1 ,kcc. C COMPRESSOR BTU ROUGH NOTICE TO APPLICANT If, after 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 VALIDATION with comply with such provisions or this permit shall be deemed revoked FURNACE FAUG IT LICENSED CONTRACTORS DECLARATION FLOOR BTU 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 WALL and Professions Code and my license is In full force and effect - } CL O License Number Lic Class ► V GI: Contractor Date O t— ❑, I am exempt under Sec d Plan check fee H B&P C for this reason - PERMIT ISSUING FEE $ Z Date Signature TOTAL FEE S 2 6 8 4,3 A OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT # 0 0 0 • • I hereby affirm that I am exempt from the Contractor s License 1 , Law for the following reason (Section 7031 5, Business and NAME • - 4625 Professions Code) I�yL�b( I as owner of the property, or my employees with ADDRESS O tp (� 2 0 wages as their sole compensation will do the work and .01 the structure Is not intended 6r offered for sale(Section CITY TEL NO 7044 Business and Professions Code) rf OWNER , ❑ I as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec- MAIL ADDRESS Loy f-L11 tion 7044, Business and Professions Code) CONSTRUCTION LENDING AGENCY CITY EL NO I hereby affirm that there Is a construction lending agency for , the performance of the work for which this permit Is Issued CONTRACTOR (Sec 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 LICENSE NO CLASS above Information is correct I agree to comply with all County ordinances and State jaws relating to building construction and hereby authorize representatives of this County to enter upon the above-mentioned roperty for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE 1�—N�(�� Signature of Applicant or Agent Date ' WORKER'S COMPENSATION DECLARATION 20-0046 DPW 9/69 APPLICATION FOR PERMIT LIME GREEN 76A364C I herelTy 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.) Policy No.•, Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV. ❑ Certified.copy is hereby furnished. ElCertified copy is filed with the county building inspection FOR APPLICANT TO FILL IN BUILDING . ADDRESS department. (PRINT OR TYPE ONLY) (_ LOCALITY Date Applicant `�--r N0. TYPE OF APPLIANCE OR EQUIPMENT FEE NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' 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($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO. PROCESSED BY I certify that inthe performance of the work for which this permit is issued, I shall not employ any person in any manner so as to BOILER,BTU become subject to the Workers'Compensation Laws. COMPRESSOR,BTU APPROVALS DTE INSPECTOR'S SIGNATURE Date Applicant VENTILATION SYSTEM NOTICE,TO APPLICANT: If, after making this Certificate of ROUGH Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER provisions of the Labor Code, you must forthwith comply with such FINAL /12 provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY LICENSED CONTRACTORS DECLARATION FLOOR BTU VA lE IDATION I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT (commencing with Section 7000) of Division 3 of the Business and HEATER: WALL Professions Code,and my license is in full force and effect. . Ci7C�GL1 C License Number Lic.Class 3.03-e,— ' , 37,07 i 36.2�+ 1 Contractor Date ITEMS 0 ❑ I am exempt under Sec. Plan Check fee TOTAL 36.24 PERMIT ISSUING FEE$ r O B.&P.C.for this reason CHECK 36..:�t � Date: TOTAL FEE 0 . Si ] A Signature PLAN CHECK APPLICANT co OWNER-BUILDER DECLARATION ``��t 't i 1111919.4 Z I hereby affirm that I am exempt from the Contractor's License Law NAME ' iA.f00-0001 for the following reason (Section 7031.5, Business and Professions L LC , Code� ADDRESS ' b.�n�9 i AM11• u J 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). NER ❑ I, as owner of the property, am exclusively contracting MAIL with licensed contractors to construct the project (Sec- ADDRESSj�" tion 7044, Business and Professions Code). �1 CONSTRUCTION LENDING AGENCY CITY 7EL.NO�� ® I performance affirm that there is a construction lending agency for CONTRACTOR the of the work for which this permit Is issued ✓ o (Sec:3097, Civ. C.). ADDRESS Lender's Name CITY TEL.NO. Lender's Address STATE LIC. 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 pr perty for inspection purp es. SEE REVERSE FOR EXPLANATORY LANGUAGE -0F APP IC A ENT DATE