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HomeMy Public PortalAbout9129 EMPEROR AVE_Mechanical__ WORKER'S COMPENSATION DECLARATION 46DPW 9,69 76A364C APPLICATION FOR PERMIT LIME GREEN, 76A3 I hereby i0firm 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.) V 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 `7 ��� 414 ` department. (PRINT OR TYPE ONLY) ADDRESS [ LOCALITY Date Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' CROSSS T. COMPENSATION INSURANCE ABSORPTION UNIT,BTU (y ASSESSOR (This section need not be completed if the work involved by the MAP BOOK PAGEARCEL O Z d permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM - ., DISTRICT NO. PROCESSED BY I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to BOILER,BTU 6 ,come subject to the Workers'Compensation Laws. ^_ I COMPRESSOR,BTU �� B O C1 �f� APPROVALS DATE INSPECTOR'S SIGNATURE pApp an ° VENTILATION SYSTEM NOTICE TO AP ANT: If, a making this Certi cROUGH Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER provisions of the Labor Code, you must forthwith comply with such FINAL provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY LICENSED CONTRACTORS DECLARATION FLOOR BTU 0 VALIDATION I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT (commencing with Section 7000) of Division 3 of the Business and HEATER: WALL Professions Code,and my license is in full force and effect. License Number Lic.Class �C Q 0. Contractor Date 1 HEMS v ❑ I am exempt under Sec. Plan Check fee }i ITAL :-10 m 55 Q B.&P.C.for this reason PERMIT ISSUING FEE$ � - e_:HEC 110455 Q Date: TOTAL FEE . 11 a Signature (n PLAN CHECK APPLICANT OWNER-BUILDER DECLARATION Z I hereby affirm that I am exempt from the Contractor's License Law NAME , �ILi—SSE 01 5/17/93 for the following reason (Section 7031.5, Business and Professions �[[gy. ...._....'sit i• o T 1 Allr�1 3 V : 1 ADDRESS I, as owner of the property, or my employees with wages a7�tl 111- a•-5 �� as their sole compensation, well 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 7 [M tion 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY CITY } TEL.NO. �"�/ � I hereby affirm that there is a construction lending agency for CONTRACTOR r , the performance of the work for which this permit Is issued (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 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 proper for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE SSIGNPREOFAPPLICANTORAGENTDATE WORKERS' COMPENSATION DECLARATION APPLICATION FOR PERMIT I PierebY,,affirm'iTiat I have a ce�tificare ofcorrsent�to self. . insure, or a•certificate of Workers,.' Compensation kTsurance,.. 76A364C HEATING - VENTILATING - AIR CONDITIONING or a certified cppy thereof (Sec. 3800,,Lab. C.) 20-0046 DPW 9/88 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 IrI tion department. (PRINT OR TYPE ONLY) ADDRESS Date Applicant LOCALITY NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST COMPENSATION INSURANCEI /� CROSS ST. QA V (This section need not be completed if the work involved by ABSORPTION UNIT, BTU I (/ DISTRICT NO. PT BY the permit is for one hundred dollars ($100) or less.) / log certify that in the performance of the work for which this BOILER; BTU AIR HANDLING UNIT, CFM r\J , permit is issued, I shall not'employ any person in any manner ffi—))— so as to become subject To the Workers' Com ensu On LOWS. APPROVALS DATE INSP CTOR'S SIGNATURE `z =zi a Date Applicnt COMPRESSOR, BTU ROUGH n NOTICE TO APPLICANT: If, after Pnoking7this 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 deem- ed revoked. FURNACE: FAU GRAVITY LICENSED CONTRACTORS DECLARATION FLOOR BTU I hereby affirm that I am licensed under provisions of Chapter 9HEATER: 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. License Number Lic. Class , O � V Contractor ate aL ❑ I am exempt under Sec. o Plan check fee B.&P.C. for this reason. ICL JJ te. -Z --,�/Z,• , PERMIT ISSUING FEE $ 00 Signature TOTAL FEE 01WIfER-BUII ER D E C L RAT PLAN CHECK APPLICANT I hereby affirm that I N am exempt from the Contractor's License ► Law for the following reason (Section 7031.5, Business and NAME u Professions Code): ADDRESS a ❑ I, as owner of the property, or my employees with F1 os wages as their sole compensation, will do the work and ;-- the structure is not intended or offered for sale (Section CITY TEL. NO. 331-1137 3 .t$ I 7044, Business and Professions Code). OWNER 1 TITEMS I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec- MAIL b TOTAL 37- 00 tion 7044, Business and Professions Code). ADDRESS CHECK _ - CONSTRUCTION LENDING AGENCY � q qf!olJ_I CITY TEL. NO. d U I hereby affirm that there is a construction lending agency for CHANGE s) the performance of the work for which this permit is issued CONTRACTOR -' , (Sec. 3097, Civ. C.). A. ADDRESS _ Lender's Name 1I l:1 '!I / g 0 t`—��lUf ?I?s/,t CITY b S� TEL. NO. / Lender's Address -C 911,710 1 7=4om I certifythat I have read this application and state that the STATE (� �r LIC. PP LICENSE NO. J / �� �j 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- ention d property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signatu e of App cant or Agent Date ©s