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Home My Public Portal About5203 DEGAS AVE_Mechanical__ WORKER'S haveCOMPENSATION DECLARATION 76A36 C . 9/89 APPLICATION FOR PERMIT LNE GREEN 20-0046 -004 C 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.) Policy No. 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 building inspection FOR APPLICANT TO FILL IN BUILDING i PY Y 9 P ADDRESS SZO �S AdE. Dalede artm (PRINT OR TYPE ONLY) Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY T.ol C. C L CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST / CROSSST. �//-/ A✓ COMPENSATION INSURANCE ABSORPTION UNIT.BTU ASS _ SSOR (This section need not be completed if the work Involved by the MAPPBOOK PAGEa's PARCe .permit is for one.hundred dollars($100)or less.) AIR HANDLING UNIT,CFM OISTBILT NO. Pfl EeSEn BY 1 certify that in the performance of the work for which this permit. is issued, I shall not employ any person in any manner so as to BOILER,BTU n become subject to the Workers' Compensation Laws. COMPRESSOR,BTU APPPOVAL$ GATE IN$PECTOn'$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 GRAVITY LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATION 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. ,{ J License Number Lic.Class D a Contractor Date 0 ❑ 1 am exempt under Sec. Plan Check fee V �1 Q B.aP.C.for this reason PERMIT ISSUING FEE 7 - O Ir- Date: TOTAL FEE 430y W Signature d OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT Z I hereby affirm that I am exempt from the Contractor's License Law NAME — r..4� O � �/ 4lzl D for the following reason (Section 7031.5, Business and Professions J/"" r Coe): ADDRESS 52J3 I',P ✓� :jC.C.I .% izI, as owner of the property, or my employees with wages as their sole compensation, .will do the work and the CITY � L�I �./7 TEL NO. � �J .1,$I)�. -1-1.45 structure is not intended or offered for sale (Section 7044, ` TT CM,_ Business and Professions Code). OWNER f— L Ct' .r ❑ I, as owner of the property, am exclusively contracting MAIL I LITAL 30 - 4c with licensed contractors to construct the project (Sec- ADDRESS CHECK tion 7044, Business and Professions Code). 7311.45 CONSTRUCTION LENDING AGENCY CITY TEL.NO. I hereby De rfo affirm that there is a construction lending agency for D CHANGE .00 the r mance of the work for which this permit Is issued CONTRACTOR (Seo. 3097,Civ. C.). ADDRESS (ILII I[I-LI[II11 10/i1/94 Lender's Name i CIN TEL NO. 1 Ar.113:113 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 CY'IreC ) K. SIGNATURE OF APPLICANT OR AGENT DATE WORKER'S haveCOMPENSATIONcertificate DECLARATION 26d04a DPW 9/e9 APPLICATION FOR PERMIT LIME GREEN 1 I hereby affirm that I have a certificate of consent to self insure, I8A364C S or a certificate of Worker's Compensation Insurance, or a certified HEATING - VENTILATING -AIR CONDITIONING copy thereof(Sec.3800 Lab. C.) CCCJJJ 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 ❑ ty 9 P .p'UZ depertme L NT(PRIOR TYPE ONLY) ADDRESS .- DaterAPPlicant LOCALITY NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST COMPENSATION INSURANCE CROSS ST. - ,y v�.. y,_ 4 ABSORPTION UNIT,BTU (This section need not be completed if the work Involved by the ASSESSORMAP BOOK .;i•r' Q b PAGE PARCFAJ��" permit Is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM DISTRICT No. PROCESSED BY I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to BOILER BTU become subject to the Workers'Compensation Laws. COMPRESSOR,BTU APPROvus wTE xar6raa•s sx3runsn: Date Applicant VENTILATION SYSTEM NOTICE TO APPLICANT: If, after making. this Certificate of I ROUGH Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER provisions of the Labor Code, you must forthwith comply with such FINAL provisions Or this permit shall be deemed revoked. FURNACE: FAU GRAVITY LICENSED CONTRACTORS DECLARATION - FLOOR BTU VALIDATION I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED—UNIT— (commencing USPENDED UNIT_(commencing with Section 7000)of Division 3 of the Business and HEATER. WALL Professions Code,and my license is in full force and affect. License Number Lk.Class } ' Conbactor Date _ ❑ I am exempt under Sec. Plan Check fee J BBP.C_for this reason PERMIT ISSUING FEE$ �. Date: TOTAL FEE •2 Signature - - OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT I hereby affirm that I am exempt from the Contractor's License Law NAME , for the following reason (Section 7031.5, Business and Professions 7�,,' , A " ��rrpa� IjI Code): ADDRESS .� I, as owner of the property, or my employees with wages v 'p^-ytom�, as their sole compensation, will do the work and the CITY lYa �.� TEL NO. l NVVw a structure is not intended or offered for sale(Section 7044, T r•[ys, Business and Professions Code). OWNER ❑ I, as owner of the property, am exclusively contracting MAIL with licensed contractors to construct the project (Sec- ADDRESS yy�tn 11 tion 7044,Business and Professions Code). ',lLlrL..•'�.tf,. CONSTRUCTION LENDING AGENCY CITY TEL NO. I.Tea�A ,J hereby affirm that there is a construction lending agency for , .,/ CONTRACTOR performance of the work for which this permit Is issued (Seo.3097,Civ. C.). +r ADDRESS Lender's Name CITY TEL.NO 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 i TUBE 01 APPLICANT OR AGENT � WiE