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Home My Public Portal About6102 ENCINITA AVE_Mechanical__ W WC rm that COMPENSATION DECLARATION APPLICATION I�®p p y SII F R L�I�RM + n rm that I have a certificate of consent to self Pri lrrlLICP91 8®OG If-�Y'l PERMIT Ifl7NLlT ins•r certificate of Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING or�,eer1tfied<o th reef (Sec. 38 Lab. C.) 76A364C 818(REV. 10/81) acy o. Company U ti7�� G Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY Certified copy is filed with the county building iaspec- FOR APPLICANT TO FILL IN BUILDING ,I y ndeparime L (PRINT OR TYPE ONLY) ADDRESS Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY /p CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST COMPENSATION INSURANCE CROSS ST. (This section need not be completed if the work Involved by ABSORPTION UNIT, BTU DISTRICT NO. PROCESSE 8r the permit is for one hundred dollars ($100)or less.) I certify that in the performance of the work for which this AIR HANDLING UNIT, CFM (J o permit is issued, I shall not employ any person in any manner BOILER, BTU so as to become subject to the Workers'Compensation Laws. APPROVALS DATE ry RecroR551GNAmRE Date Applicant COMPRESSOR, BTU ROUGH NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL / / Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth. EVAPORATIVE COOLER VALIDATIO with comply with such provisions or this permit shall be xf deemed revoked. I F OOR CFURNAF. FAU BTU GRAVITY LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9HEATER: SUSPENDED—UNIT— (commencing USPENDEDUNIT_(commencing with Section 7000) of Division 3 of the Business WALL and Professions Code,and my license is in full force and effect.�' S ❑ N1VLicense Number 103735 LicClasss �Contractor (!!!d �D � vO H V am exempt under Sea' Plan Check fee d B.BP.C. for this reason' PERMIT ISSUING FEE j ) Z Date: ' 0,1 :1, 2 A FEE TOTAL oW Signature # !"o 8 OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT ' I hereby affirm that I am exempt from the Contractor's License I�° *.* Q50 Low for the following reason (Section 7031.5, Business and NAME D e s e e (1Or 05 Professions Code): '❑ I, as owner of the property, or my employees with ADDRESS O Q 7 $�8 8 wages as their sole compensation,will do the work and the structure is not intended or offered for sale(Section CITY TEL. NO. 7044, Business and Professions Code). ,OWNER 2 A145c') /v 2.0.1 1,3 A ❑ I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec- WAILw�i y #.e•° a e,e 8 O tion 7044, Business and Professions Code). ADDRESS CONSTRUCTION LENDING AGENCY CITY TEL. NO.�g� hmad� I hereby affirm that there is a construction lending agency for _ D te performance of the work for which this permit is issued CONTRACTOR �(/�VOf/j i I/VAA/1 er (Sec. 3097, Civ. C.). / _ _. ADORES 3 N, .-.2 G5 .0 Lender's Name CITY TEL- NO 6 Q JS e ° ° 20L50=0 Lender's Address _ v STATE 9 2 LIC. �r 1 n /� Q• O 0,7 a—S a I certify that I have read this application and state that the LICENSE NO. D_J7 ..5 CLA$$S L��a _ 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 up th mentioae perry fo ctian pur�oses. SEE REVERSE FOR EXPLANATORY LANGUAGE _24- Signature of Applicorn or Agent Date\9 VI WORKERS'COMPENSATION DECLARATION � 76A364C r CE-818'(2.8 I hereby affirm tsar I have a certificate of consent to self 0) APPLICATION FOR PERMIT, insure, or a certific,'V of Workers'Compensation Insurance,or HEATING-VENTILATING-AIR CONDITIONING a certified copy jjthe.�''',yoo��f77(3ec`. 3800, Lab. C.) �; ,r ' Policy No._1—Z-IS37zmpany zlf7-&—(!4f/ ❑ Certified copy is hereby furnished. COUNTY OF.LOS ANGELES BUILDING AND SAFETY ❑ Certified copy is'filed with the county building ins action FOR APPLICANT TO FI LL IN BUILDING -rfs�D � � ADDRESS Dale 1PIlcant_ (PRINT OR TYPE ONLY) LOCALITY ^if '� ' e�Ty CERTIFICATE OF EXEMPTION FROM WORKERS' NO, TYPE OF APPLIANCE OR EQUIPMENT FEE COMPENSATION INSURANCE NEAREST n -4 / O (This section need not be completed if the work involved ABSORPTION UNIT, BTU CROSS ST. CD by the permit is for one hundred dollars ($100) or less.) DISTRICT NO. PROCESS///EJJJ�BV U I certify that in the performance of the work for which this AIA HANDLING UNIT,CFM / ,(.� cc permit is issued, I shall not employ any person in any manner ;� f®/] //f O So as to become subject to the Workers' Compensation Laws. BOILER, BTU—(��-�"V �" APPROVALS DATE INSPECTOR'S SIGNATURE W Date Applicant COMPRESSOR,BTU ROUGH - r-- N NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL Z Exemption, you should become subject to, the Workers' Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION with comply withsuch provisions or this permit shall be deemed revoked. FURNACE: FAU— GRAVITY_ " LICENSED CONTRACTORS DECLARATION FLOOR: BTU d 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. ty.� (' License Number lJ �+ Z'� Lic.Class +_- Contractor-,5i��2e- Date_C�" /_l_� ❑ I am exempt from the licensing requirements as 1 am a licensed architect or a registeredprofessional engineer Plan cheek fee 25%of above. acting in my professional capacity (Section 7051, Bus- iness and Professions Code). _ PERMIT ISSUING FEE $ Lia or Reg.No. Date TOTAL FEE �,�0 2 9 0,O,A HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT I hereby affirm that I am exempt from- the Contractor's NAME / .I�_ 2e e 3 Q 5.0 License Law for the following reason (Section 7031.5, Busi- -//� ness and Professions Code): ADDRESS �0— �i 30 5.0 m' ❑ L as owner of the property, will do the work and the CITY "T �� C!r-� TEL. NO.L�3�` structure is not intended' or offered for sale (Section L � 0)6 1 6,-83 7044, Business and Professions Code). ❑ ��.-�Fj . I, as owner of the property, am exclusively contracting OWNER with licensed contractors to construct the project MAIL (Section 7044, Business and Professions Code). ADDRESS CONSTRUCTION LENDING AGENCY CITY TEL.NO. I hereby affirm that there is a construction lending agency CONTRACTOR for the performance of the work for which this permit is issued (Sec. 3097,Civ.C.). Lender's Name ADDRESS C/6 -Jc C},0,51— Lender's Address /� CITY 5AA,/ wI�J' TEL. NO. 33CF,-f192J` I certify that I have read this application and state that the STATE _ �u-.p� LIC. T above information is correct.I agree to comply with all County LICENSE NO.' L-. V CLASS ordinances and State laws regulating Heating, Ventilating and Air Conditioning,'and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE County to enter upon the above-mentioned property for - inspect" IT purpo'a- Signa`,-..•fe of P ..r t . Date