The URL can be used to link to this page

Home My Public Portal About10653 DANBURY ST_Mechanical__ WORKERS COMPENSATION DECLARATION `;_ 0-004 76A36 CDPW 9/89 - APPLICATION FOR PERMIT G I hereby affirm that I,have a certificate of consent,to self insure, GREEN or acertificate of Worker's Compensation insurance, or a certified - - HEATING-,VENTILATING-AIR CONDITIONING copy thereof(Sec.3800 Lab. C.) - Policy No. - CompanyCOUNTY OF LOS ANGELES - DEPT OF'PUBLIC WORKS BUILDING AND SAFETY DIV. Certified copy is hereby furnished. -, ❑ Certified copy is Tiled with the county building inspection FOR APPLICANT TO FILL IN - AD�RE86 / 5f j �-• 1 /+♦i [J ' department - (PRINT OR TYPE ONLY) ! L• .J•!. f.� flat. .�- Date Applicant NO. •TYPE OF APPLIANCE OR EQUIPMENT ,.-FEE LOCALITY CERTIFICATE OF EXEMPTION'FROM WORKERS: NEAREST1 . +!' j' +' ` ✓ COMPENSATION INSURANCE CROSS ST. ABSORPTION UNIT,BTU r This section need not be completed if the work involved b the ASSESSOR ( P ,. .Y MAP BOOK PAGE PARCEL permit is for one hundred dollars f the or less.) AIR HANDLING UNIT,CFM DISTRICT W. 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'5 SIGNATURE Dale �� - /l-- 'Applicant �'�••�" VENTILATION SYSTEM NOTICE TO APPLICANT: If,-alerr--making this Certificate of ROUGH ' Exemption,you should become•su`bject to the Workers) Compensation EVAPORATIVE COOLER 'provisions of the Labor Code, you must forthwith'comply with such r. .0 ", T` FINAL - provisions or this permit shall be deemed revoked. f FURNACE: :/FAU ✓ GRAVITY_- - 'LICENSED CONTRACTORS DECLARATION f FLOOR BTU -sr rr;'' VALIDATION , hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED—UNIT— (commencing USPENDED UNIT_(commencing with Seption 7000) of Division 3 of the Business and HEATER: WALL Professions Code,and my license is in full force and effect. 14 C License Number, vt / `rJ/- / Liu Class - aa Contractor s' +v Date �yvTr�6 0 J ❑ am exempt W:C undersec.^ Plan check fee +• 1,l J e BP.C.for this reason PERMIT ISSUING FEE$ •.!' t:_ I7 LL Date: TOTAL FEE. Signature PLAN CHECK APPLICANT ! (•µ �•{ - OWNER-BUILDER DECLARATION - INWE i O 1 hereby affirm that I am exempt from the Contractor's License Law NAME q D +.�myWE a for.the following reason (Section 7031.5, Business and Professions Code): ADDRESS UJ ❑ 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 r -1. as owner of the property, am exclusively co ntracting� MAIL with licensed contractors to construct the project (Sec- ADDRESS - _ tion 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY CITY'9 �j yr TELNO f r. '- herebyaffirm that there is a construction lendingagency for + the perormance.of the work for which this perit s isued CONTRALTOR 'S-'� (Sec.3097,Civ, C.): - ADDRESS f• - - ' Lender's Name - �• - - - 'TEL NO. - ,J1,.J Lender's Address - ' STATE'" r; / ; LIC. I certify that I have read this application and state that the above• LICENSE No. _/ / i/ .� CLASS information is correct. I agree to comply with all County ordinances - and Slate laws relating to building construction,and hereby authorize representatives of this County to enter upon the above-mentioned - - properly,for,inspection purposes. t d + BEE REVERSE FOR EXPLANATORY LANGUAGE SIGNATURE OF APPLIC^TOR AGENT DATE WORKER'S have COMPENSATION DECLARATION 76A3f C 9/69 APPLICATION FOR PERMIT URAE GREEN 0A 6 I hereby affirm that.l have a certificate of consent to self insure, �r or a certificate of;7Qrker'$ton5'pensefion Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING SIIJ'I 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. ❑ Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN BUILDING department. (PRINT OR TYPE ONLY) ADDRESS Date Applicant LOCALI NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST COMPENSATION INSURANCE CROSS ABSORPTION UNIT,BTU ASSESSOR (This section need net be completed if the work involved by the MAP BOOK PAGE PARCEL permit is for one hundred dollars($100)or lase.) AIR HANDLING UNIT,CFM DISTRICT NO. PROCESSED By I certify that in the performance of the work for which lois permit �/� is issued, I shell not employ any person in any manner so as to BOILER.BTU 08 become subject to the Workers'Comp a n Laws. (�j/ ��_VVVV r: COMPRESSOR,BTU 90 AppgOVAIS GATE •INBPECTOR'8 SM.NAN / Date 2 '�i ppli..anl, VENTILATION SYSTEM NOTICE TO APPLICANT: If,. r making this Certificate of ROUGH Exemption,you should becom subject to the Workers'Compensation EV O TIVE COOLER provisions of the Labor Code, you must forthwith comply with suchefFINAL ' provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATION I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT_ (commencing with Section 7000) of Division 3 of the Business and WALL Professions Code,and my license is in full force and effect. '�/ U 4Li / License Number Lic.Class Q Contra cipr' Date 7- 7,9 �/ - D 0 ❑ Plan check fee v ACCT.: m exempt under Sec. Q 3307 11)6.AS B.BP.C.for this reason PERMIT ISSUING FEE$, Date: TOTAL FEE 0 1 ITEMS P W Signature - TOTAL 106 ® 6505 PLAN CHECK APPLICANT OWNERBUILDER DECLARATION _ CHECK .1Z I hereby affirm that I am exempt from the Contractor's License Law NAME for the following reason (Section 7031.5, Business and Professions D CHANGE Code): ADDRESS ❑ 1, as owner of the property, or my employees with wages rt as their sole compensation, will do the work and the CITY TEL NO. UG00-0011 11 4/93 structure is not intended or offered for sale (Section 7044, J Business and Professions Code). OWNER x 1 11 07 1 AN t 21:41 ❑ I, as owner of the properly, am exclusively contracting MAIL with licensed contractors to construct the project (Sec- ADDRESS tion 7044,Business and Professions Code). ` CONSTRUCTION LENDING AGENCY CITYA'A .TEL.NO. I hereby affirm that there is a construction lending agency forCONTRACT R i D the performance of the work for which this permit Is issued (Sec. 3097,Civ.C.). - ADDRESS Lender's Name CITU TEL.NO. Lender's Address STATEh LIC. I certify that I have read this application and state that the above LICENSE NO.� CLASS G 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 propefty'tol inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Z ,Z7 SIGr E OF APPLI R AGEr DATE