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Home My Public Portal About9914 DUFFY ST_Mechanical__ WORKERS'COMPENSATION DECLARATION:. 76'A364C p p I.hereby :affirm that I• have a',certificate_ Of consent-to self,:: CE-818 (2 8A1 p insure, or a certificate of Workers'Compensation Insuranc o a certified cony thereof(See.3900,'Lab.C.) iEA TIRIC9 bE:R1TlL,AY'INCv-Alli CONDITI®N16�t9 , y3ibq-Fs `.Policy No. _ ompany_�T�.'tli�-r `�•"'-� " . l Certified•copy is.'Iiereby furnished. COUNTY OF LOS ANGELES BUILDING.AND SAFETY" Certified copy is,'fiied.with the county building inspection,,, 160ILDIING department FOR APPLICANT TO FILL IN ADDRESS Date ,Applicant (PRINT OR TYPE ONLY) ,- LOCAL TY 4i ' GERTIFICATE OF EXEMPTION FROM WORKERS No. TYPE OF AP,PLIANC,E'OR EQUIPMENT 'oFEE I COfvlPENSATION INSURANCE.. �U`-^o"v (This section. need not be completed if.the work involved • ABSORPTION UNIT, BTU ,F, -C;ROSS ST � .+� CLby-thiSe permit . 'for. one'hundred-dollars'($100) or less.)* DISTRICT NO , PROCESSED 8Y o' ' AI`R H 4NDLING=UNI-T;CFMcc „I'certify that m the.,performance of the work for which this:: � —. ., permit is issued I shall not employ any person,,in any manner.' __ �� so as to.become subject to the Workers',Compensation Laws.` BObLER,BTU -- APPROVALS a DATE NSP OTOR'S51W T i U Date Applicant COMPRESSOR .BTUs — — — W OU_GH Y fJ 0. R' NOTICE TO APPLICANT: If;after'maiking this Certificate of VEt>(TILgTION SY$FEM i� Exemption; you'should''become' subject to .fhe 'Workers'•. " FINAL Compensation provisions of the Labor Code,:you must forth-.r i Z fi. with comply with,such provisions or,.this permit shall be EVAPORATIVE COOLER ALIDATI�N `deemed revoked. FAUX___ G RA V 1 Y - FURNACE''. '�' , 4 LTC'ENSED.CONTRACTORS.DECLARATION FLOOR. EtTU=_ _ - `� V I hereby affirm that 1 am'Iicensed under provisions.of Chapter,, .a HEATER: SUSPENDED UNIT ". 9 (commencing with Section 7000)of Division`3 of the Bus- WALL. ness-and"Profee .oils Co.de,.and my'Iicense is in full force'.,and effect. r Lice Ni nae %8 It Lic.Class_ a � , d Contracto __ Date—1 - a " Q' I a t•exe opt,from the licensi ng reyuii•emenYs as I am a � ; •`� r� lic+nsed archit"ect or;a registered professional engineWl-, Plan CheCiC..fee 25%of RboVe ac ing i' 'my'professional capacity (Section='7051 Sus- inE'c .d Professiops'Code), PE-RMIT ISSUING-€,E.E $ Lid.or Reg,No Date TOTAL,FEE: , a HOIYIE OWNER-liUlLL)ER`DECLA'RATION PLAN CHECK AtSPLiCANT ^L I herebj.affirm that I exempt fro#n the Contractors' NAME °. License'•Law for'ti e following reason (Section 70.31.5, BUM ness and Professions Code): ADDRESS '(I 294A Ell, as. owner,-of,the property, 'will do•the,work and the structure is nqt'intended. .pr offered for sale-(Section CITY TE�.-N.O o'o o eao 7044,Business and Professions Code). I 6 OWN ER `p, �'Vl'C�IIZLL.O zJqi-. OJO I, as owner of the property,"am exclusively 'contracting with ,licensed contractors to construct the project AMAIL DDRESS 2 Q 6 0"r: (Section 7044, Business and Professions Code). a CONSTR JCT10N LENDING 4GENCY. CITY .� �,t . TEL NO. .Q gi2'^�I=8 4. I hereby affirm that:there is-a .construction lending,agency r�� y�n� �+ P for the performance of.the work for Which this permit, is, CONTRACTOR,. s G'/vI G�-1'�N�`'i issued(Sec. 3097,Civ.C.). x Lender's Name ADDRESS,Lender's Address - CIT.Y TEL'NO.. - CxAI LUQ--: `,G`A I certify that 1,have read this'application and state that ttie STATE ^ L i Q� LIC. above information is correct.I agree to comply with all County LICENSE NO. 0� 1y GLASS ordinances and`State laws:regulating'Heating, Ventilating and Air'Con B°'ening ^,,� hereby authorize representatives of this SEE REVERSE FO•,R EXPLANATORY LANGUAGE County to .r.r upon the above-mentioned property for. inspect on pur, .ees. Signatw Sf P rmittee Date _ WORKER'S COMPENSATION DECLARATION 20-0046 DPW 9/89 n PPLICAM ^ F® .PERNTUME 76A364C 1wl uVu REE LI U n I hereby affirm that I have a certificate of consent to self insure, 6 ora 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 DEP•T,OF-PUBLIC WORKS' BUILDING AND SAFETY DIV. Certified copy is hereby furnished. BUILDING ❑ "Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IM, ADDRESS department. (PRINT OR TYPE ONLY) Date - Applicant - - LOCALITY NO. TYPE'OF APPLIANCE OR EQUIPMENT FEE •.•. .. NEAREST .. CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST.` a� TION INUACE (This section'need no.COtnbe coAmpletedSf.theNwork.involved,by the ABSORPTION UNIT,BTU 14. MAP BOOK -p G3 PAGE ` t PARCEL permit is for one hundred,dollars($100)or less.) AIR HANDLING UNIT;CFM DISTRICT NO. PROCESSED BY certify that,in the performance of.the work for which this permit is issued, I shall not employ an erson in an manner so as to P Y Y'P Y BOLWR• T' �y become subject to the Workers'.Compensation Laws. 0,0 d COMPRESSOR,BT DateZ li = APPROVALS DATE>.. INsPECT_OR'sSIGNATURE 4pcantVENTILATION'SYSTEM NO ---[TO • APr LICAN7: 1f, after making'this Certificate of ROUGH ` Exempti ,you should become-.subject to,the Workers'Compensation EVAPORATIVE COOLER e provisions of the Labor Code, you must forthwith comply-:with'such FINALIdM IV' provisions or this permit shall be.deemed revoked.. FURNACE: FAU GRAVITY- - LICENSED CONTRACTORS DECLARATION FLOORBTU 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'mylicertse is in full force'arid effect.-• License Number 3 ' 1 Lic Class r" /y A Contractor 11 LIM LSC Date ❑ Plan check fee U am exempt under.Sec. 4 $ / B.&P.C.for this reason' - PERMIT ISSUING FEE. �7J 1 �U Date: TOTAL FEE D Signature PLAN CHECK APPLICANT OWNER-BUILDER DECLARATION -' u z I hereby affirm that ['am exempt from the Contractor's License,Law NAME D V for the following_reason (Section:7031.5„Business and ProfessionsA f+ g4. Code): ADDRESS .. - _ .. ACC T r.:•: ❑ I; as owner<of the'property, or my employees with wages 's 7 46a as their sole'compensation, will do the work and the CITY TEL NO structure is not intended or offered for sale (Section 7044, 1 ITE Business and Professions Code). OWNER y TOTAL �-�0 9.3 I, as owner of the property, am exclusively contracting MAIL 1 1 with licensed.contractors to construct the project (Sec- ADDRESS - ^•(_AGS !).0+,00 tion 7044, Business and Professions Code). r� CITY TEL.NO. /+L� /- CONSTRUCTION LENDING AGENCY CHANG� 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.). ` �/J D } syn{ p/ i /�} ADDRESS 7 /7 A1C VUIJV I�V1 s +�1!.•7 Lender's Name (� p q CITY TEL.NQ.g�6�7b —Z�� 282 r l Lender's Address " I certify that I have read this application-and state that the above uCENSE 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 `• - �'" ' SIGNATURE OF APPLICANT OR AGENT DATE - _ - •• -- - - -, - •.