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Home My Public Portal About5438 ENCINITA AVE_Mechanical__ WORKER'S COMPENSATION DECLARATION 20-0046 DPW 9,69 APPLICATION FOR PERMIT I hereby affirm that I have,a certificate of consent to self insure, 76A364C L�� ME 'PREEN or a'certificate of Worker's Compensation Insurance, or a certified HEATING -VENTILATING -AIR CONDITIONING copy thereof.(Sec.3800 Lab.C.) Policy No. 229 Company ate fUrld COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV. Certified copy is hereby furnished. 60 Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN BUILDING SS 8 N lid A � `,�, department. (PRINT OR TYPE ONLY) Date 5-16-95 Applicant :TEMP Til LOCALITY g��Je city Pp NO. TYPE OF APPLIANCE OR EQUIPMENT FEE NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' ^ CROSS ST. C�4�Sr-' ' COMPENSATION INSURANCE ABSORPTION UNIT,BTU 71� �'c,f�O�� !. This section need not be completed if the work involved ASSESSOR ( b P Y the MAP BOOK 5"P-19' PAGEQg/ PARCEL 0�/ - permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO. PROCESSED I certify that in the performance of the work for which this permit f is issued, I shall not employ any person in any manner so as to BOILER,BTU c // become subject to the Workers' Compensation Laws. r +� COMPRESSOR,BTU • APPROVALS DATE INSPECTOR'S SIGNATURE Date Applicant VENTILATION SYSTEM NOTICE TO APPLICANT: If, after making this Certificate of ROUGH Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER provisions of the Labor Code, you must forthwith comply with such FINAL provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY LICENSED CONTRACTORS DECLARATION Z FLOOR BTU.2 890 - VALIDATION 19 I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT (commencing with Section 7000) of Division.3 of the Business and WALL Professions Code, and my license is in full force and effect. License Number 609931 Lic.Class B 1 } Nagle BAlders, Inc 5-16-95 r., p Contractor Date ❑ '=-"•�`n check fee 1 i 33 1,7u c U I am exempt under Sec. Plar`�1" B.&P.C.for this reason PERMIT ISSUING FEE$ 6 T--- 5-16-95 - �:t., Date: TOTAL FEE TC,,Ts3 1 _`9 „ ;B_A W Signature 7ny d PLAN CHECK APPLICANT Ja�s ;;";Y•,.;: I t?;;�:.,,t co DECLARATION __ co I herebyaffirm that I am exempt from the Contractor's License Law (_ - .UH P NAME I le'13l]11C Il]C, s s+ i for the following reason (Section 7031.5, Business and Professions r Code): ADDRESS4-M �uer T r � ❑ I, as owner of the property, or.my employees with wages r,'I f1 =/'I7/.^=_ as their sole compensation, will do the work and the CITY; le TEL.NO.,81_350-1227 structure is not intended or offered for sale (Section 7044, - A �c i Business and Professions Code). OWNER jaT2s & Trlr.,L5rii ❑ I, as owner of the property, am exclusively contracting MAIL With licensed contractors to construct the project (Sec- ADDRESS 47M Meller 1)., B-5 tion 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY CITY r L„,�1e Ci TEL.N0.318-3 -129-7 I hereby affirm that there is a construction lending agency for CONTRACTOR , the performance of the work for which this permit Is issued 0. c 'aildeem, im, (Sec.3097,Civ. C.). ADDRESS 47601 mi-ner .Dr., # B-5 Lender's Name CITY ttl . ` City TEL.NO.218-X 1.227 Lender's Address STATE LIC. certify that I have read this application and state that the above LICENSE NO.509931CLASS B 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 5-16-95 F APPLICANT OR AGENT DATE WORKER'S COMPENSATION DECLARATION 20-0046 DPW 9/89 I hereby affirm that I have a certificate of consent to self insure, APPLICATION FOR PERMIT 76A364C LIME GREEN or a certificate of Worker's Compensation Insurance, or as certified HEATING -VENTILATING -AIR CONDITIONING copy thereof(Sec. 3800 Lab. C.) " Policy N� — Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV. ^❑ Carl,ied cS is Ve y furnished. LN Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN BUILDING s1 p Z.GeR� department. (PRINT OR TYPE ONLY) ADDRESS J O Date ` Applicant LOCALITY NO. TYPE OF APPLIANCE OR EQUIPMENT. FEE f CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST CROSS COMPENSATION INSURANCE ABSORPTION UNIT,BTU ASSESSOR (This section need not be completed if the work involved by the MAP BOOKPAGE�� PARCEL permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO. PROCESSED BY I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to BOILER,BTU D D become subject to the Workers' Compensation Laws. % / D - COMPRESSOR,BTU (o U APPROVALS DATE INSPECTOR'S SIGNATURE Date Applicant VENTILATION SYSTEM NOTICE TO APPLICANT: If, after making this Certificate of ROUGH -22 ,f. Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER provisions of the Labor Code, you must forthwith comply with such FINAL provisions or this permit shall be deemed_revoked. FURNACE: FAU GRAVITY LICENSED CONTRACTORS DECLARATION / FLOOR BTU _ G(p 6t� VALIDATION I hereby affirm that I am licensed under provisions of Chapter 9 HEATERSUSPENDED UNIT V : (commencing with Section 7000) of Division 3 of the Business and WALL Professions Code,and my license is in full force and effect. ACCT.* o License Number �A dO / Lic.Class ,v 0 L^ iJ Q 33 03 77.30 I ITEMS �. Contractor , TOTAL 97-30 p F1 am exempt under Sec. Plan Check fee CHECK 97.30 � B.&P.C.for this reason PERMIT ISSUING FEE$ CHANGE .00 O Date: TOTAL FEE fy (� W Signature PLAN CHECK APPLICANT WOO-0001 I?{r/�i 7/?5 0- OWNER-BUILDER DECLARATION 364T I AM I hereby affirm that I am exempt from the Contractor's License Law NAME , 364 a22 for the following reason (Section 7031.5, Business and Professions Code): ADDRESS ❑ 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 f I, as owner of the property, am exclusively contracting MAIL with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code). CITY �/' TEL.NO. �I CONSTRUCTION LENDING AGENCY F✓` �a� I hereby affirm that there is a construction lending agency for CONTRACTOR L , the performance of the work for which this permit Is issued 'PSC/ (Sec.3097,Civ.C.). ADDRESS Lender's Name CITY TEL.NO. Lender's Address STATELIC. 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 rty r inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE ,prop SIGNATURE OF LI ANT R NT DATE