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Home My Public Portal About5946 ENCINITA AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION � CE 81 C APPLICATION 1pp /'spy N C R pp[I I hereby affirm that I have a' certificate of consent to self CE-816 (2-80) P'i I� r L�Lr PY 1 Q I ti r Of'( PERMIT �� insure, or a certificate of Workers'Compensation Insurance,or HEATING-VENT ILATI NG-AIR CONDITIONING a certified copy thereof(Sec.3800,Lab.C.) Policy No. Company ' ❑ Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUI LDING AND SAFETY Certified�nupy' .filed with [F. ,rvari�, ba'.fing inspection BUILDING �� d,.:. fie(e n FOR APPLICANIT TO FILL IN ADDRESS Uate.�!_/_ b Applicant_ _ — (PRINT OR TYPE ONLY) LOCALITY CERTIFICATE OF EXEMPTION FR6MWORKERS' NO, TYPE OF APPLIANCE OR EQUIPMENT FEE COMPENSATION INSURANCE NEAREST (This section need not be completed if the Work involved ABSORPTION UNIT, BTU CROSS S �� // r a by the permit is for one hundred dollars ($100) or less.) pISTRICT NO. " PROCESSEp BY O 1 certify that in the performance of the work for which this AIR HANDLING UNIT,CFM— permit FM ! n / permit is issued, I shall not employ any person in any inanner LJl V (O/ 0 so as to become subject to the Workers' Compensation Laws. BOILER, BTU i �r,E_ �,��r� - APPROVALS DATE INSPECTO IGNATURE U Date Applicant { COMPRESSOR, BTU Il ¢ `r'!c%� �� " W ROUGH ,,....- ' NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL w1t- Z Exemption, you should become subject to the Workers'- Compensation provisions of the Labor Code, you most forth- EVAPORATIVE COOL - VALIDATION - with comply with suchprovisions or-this permit ,shall be v deemed revoked. / FURNACE: FAD_ '; AVIT �9... /O LICENSED CONTRACTORS DECLARATION ( FLOOR: BTU-2. — 1 hereby affirm that I am licensed under provisions of Chapter HEATER: SUSPENDED UNIT 9 (commencing with Section 7000) of Division 3 of the Busi- WALL _ ness and Professions Code, and my license is in full force and effect. ryry..//r�te�//rr__ License Number-O.lfY_ Lia Class— +., n Coatractorw— r�. Date_ ❑ 1 am exempt from the licensing requirements as I am a , licensed architect or a registered .professional engineer Plan Check.fee 25%of above. acting in my professional capacity (Section 7051, Bus- iness and Professions Code). PERMIT ISSUING FEE $ p Lic.or Reg,No. Date, TOTAL FEE HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT- 1 hereby affirm that I- am exempt fiont -the Contractor's NAME - License Law for the following reason (Section 7031.5, Busi` - z ness and Professions Code): -ADDRESS 0 9 7,51A ❑ 1, as owner of the property,'will do the work and the �� ea 8 structure is not intended or offered for sale (Section CITY TEL.. NO. 1 7044, Business and Professions Code). - 2'a(e j Q,5 0 ❑ OWNER t 1, as owner of the property. am exclusively contracting with licensed- contractors to construct the project MAILallP to 3j 0,150 mo (Section 7044, Business and Professions Code), ADO HES p `(_� L�N /_/"7 CONSTRUCTION LENDING AGENCY CITY / v -TEL.N /l-7f/J}t'[� Q CJ.-Q-4,-8 4 I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is CON TRAC TOF issued(Sec. 3097,Civ.C.). n — Lepder's Name - ADDRESS Lender's Address CITY V ✓r` TEL.Nr . I certify that I have read this application and state that the 'STAT LIC. above information is correct.I agree to comply With all County LICENSE NO: '2__ _ CLASS ordinan es and State laws regulating Haating. Ven tilut ing and - Air C< udiP-ning,and hr ebypurhorize re presen[atives of this 'SEE REVERSE FOR EXPLANATORY LANGUAGE Cc n'� T anti opo the above-mentioned Property f� WORKER'S COMPENSATION DECLARATION 200046 DPW 9189 APPLICATION FOR PERMIT. I hereby affirm that I have a certificate of consent to self insure. T6A3 C .. or a certificate of Worker's Compensation Insurance, or a certified - ,'-HEATING_VENTILATING • AIR CONDITIONING cop thereof(Sec.3600 Lab.C.) ( �/-03oil-Ol0. � /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 BUI eSG ` A 1 L department. _ ' (PRINT OR TYPE ONLY) LOCALITY Date Applicant C NO. TYPE OF APPLIANCE OR EDUIPMENT FEE ETIFICATE OF EXEMPTION FROM WORKERS' CROSSST tad ABSORPTION UNIT,BTU ASSESSOR - COMPENSATION INSURANCE CROSS- (This section need not be completed if the work Involved by the MAP BOOK PAGE PARCEL permit Is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO. PROCESSED 01 1 certify that in the performance of the work for which.this permit is issued, I shall not employ any person in any manner so as to BOILER,BTU /^ O t become subject to the Workers'Compensation Laws. - J • G l/. COMPRESSOR,BTU - .. APPROVALS DATE INSPECTOR'S SIGNATURE Date Applicant VENTILATION SYSTEM NOTICE TO APPLICANT: If, after making this Certificate of _ - _ _ ROUGH Exemption,you should became subject to,the Workers' Compensation EVAPORATIVE COOLER provisions of the Labor Code, you muSCforthwith,comply with such FINAL A.Z provisions or this permit shall beideemed revoked. FURNACE: FAU_GRAVITV LICENSED CONTRACTORS DECLARATION FLOOR BTU VAL ATION ' I hereby affirm that I am licensed underprovisions of Chapter 9SUSPENDED -UNIT_ - (commencing with Section 7000) of Division 3 of the Business and HEATER: WALL DV . Professions Code,and my license is in full force and effect. License Number� 7/V / LIC.Class / D as contryctor Date L IL�J� Plan checkk fee I am exempt under Sec. � e.&P.C.for this reason - - - - PERMIT ISSUING FEE$ - - - - _ 0 Dala: \ TOTAL FEE . .. . a Signature /L/ [,(/el/Yi (t/• ' 1 _ Cl) 7 A N PLAN CHECK APPLICANT OWNER-BUILDER DECLARATION Z I hereby affirm that I am exempt from the Contractor's License Law NAME D for the following reason (Section 7031.5. Business en6 Professions Code): ADDRESS ❑ I, as owner of the properly, or my employees with wages - n4lT i 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 _ - _ ❑ LT - 4 I, as owner of the property, em exclusively contracting MAIL i 1I_17•= with licensed contractors to construct the project (Seo. ADDRESS TOTAL 25 . 00 tion 7044, Business and Professions Code). [ CONSTRUCTION LENDING AGENCY Cm ;, TE . P _ CHECK .`_1e111J I hereby affirm that there is a construction lendingagency for CONTRACTOR (� r' the performance of the work for which this ermlt Is issued U - JA - �-••�rl (Se3097 Civ.C). p ADDRESS a Lender's Name CITY TEL. ! $� .Ii 1 l�-1_INTI Lender's Address _ _!_ .__ _ _._ _ __. _�_ -_ _. -._- '0 lo STATE LIC: - . --!�- r- -�•"�—^••�{,il�'':S'_ I certify that I have read this application and stale that the above LICENSE NO, U 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 _ pr petty for inspeotioDp poses. q SEE REVERSE FOR EXPLANATORY LANGUAGE Ael T A AN I OR AGENT ATE -