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HomeMy Public PortalAbout10526 FREER ST_Mechanical__ WORKERS' COMPENSATION DECLARATION " APPLICATION FOR PERMIT I hereby affirm that, I haves.a certrficdte of consent to self insure, or a certificate of Workers' Compensation Insurance; HEATING - VENTILATING - AIR CONDITIONING or a ce±tifiec.�c0 y thereof (Sec. 3800, Lab. C.) 76A364C 20-0046 DPW 9/88 s 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 !ion.depar!ment. ' _ '(PRINT OR TYPE ONLY) � ADDRESS , Date Applicant LOCALITY NO TYPE OF APPLIANCE OR EQUIPMENT FEE i 7 CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST COMPENSATION INSURANCE CROSS ST. ABSORPTION UNIT, BTU (This section need•not be completed if the Work involved by DISTRICT NO PROCESSED BY 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 Perm it is issued;I shalknot employ any person in anVmanner BTU • 50 q5 10 be ome subject to the Workers' Com Tion Laws. BOILER, _ APPROVALS DATE NSPECTOR'S SIGNATURE Dated �U Applicant COMPRESSOR, BTU �� d OJ ROUGH. In NOTICt TO APPLICANT: If, of ing this Certificate of VENTILATION SYSTEM FINAL Ezernption, you'•should become subject to the Workers' Compensation provisions'of the Labor Code, you must forth- EVAPORATIVE COOLER V LI ATIO with comply with such provisions or this permit shall be deem- " ed revoked. FURNACE FAU GRAVITY ��— LICENSED CONTRACTORS DECLARATION FLOOR BTU Uu �dv ' I hereby affirm that I am'jicensed_under provisions of Chapter 9 HEATER. SUSPENDED UNIT_ (comm'encIng 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 C;_1) , 0 O Contractor- Date ( G� ❑ o I am exempt under Sec. Plan check fee u W B.BP.C. for this reasonV H Date: PERMIT ISSUING FEE $ Z Signature TOTAL FEE 3 OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT I hereby affirm that I am exempt from the�Contractor's License Law for the following reason (Section 7031.5,-Business and -NAME 5 ( ► Professions Code): ADDRESS' 7? J F-1 1, as owner of the property, or my employees with �� l wages as their sole compensation, will do the work and ACCT.IT' The structure is not intended or offered for sale(Section CITY � S�W TEL.NO - 7044, Business and Professions Code). OWNER / 1v13? 63J.13 t ❑ j, as owner of the property, am exclusively contracting 1 ITEM; with licensed contractors to construct the project (Sec- MAIL tion 7044, Business and Professions Code). ADDRESS I l • rjr7l,11-0 AVE TOTAL 63 . 00 CONSTRUCTION LENDING AGENCY CITY_ TEL NO „�/13>� —� r I hereby affirm that there is a construction lending agency for CHECK 6`'r. IL! the performance of the',work for which this permit is issued CONTRACTOR oil. C.NANGE .013(Sec. 3097, Civ. C.). ADDRESS Lender's Name CITY TEL NO 0000-0001 5/13/90 Lender's Address _ _ ' STATE LIC I certify that I have read this application and state that the LICENSE NO L7' d CLASS 0779 1 AM 10:14 above information is cor t. I agree to comply with all County ordinances and aws relating to building construction, andh eb orize representaTives of this County to enter, upoproperty for in ection purposes „SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent Date , tis WORKERS' CI have COMPENSATION-DECLARATIONf con; APPLICATION FOR PERMIT I herebyaffirm that t have A certficafe of consent to self insure; o'r a certificate of WorkersS,Compensation•Insurance, or a certified copy thereof (Sec. 3QO, Lab. C.) 76A364C HEATING - VENTILATING •- AIR CONDITIONING '20-0046 DPW 9/88 ' R, Policy No. Company _ 't Certified copy is hereby furnished:-; COUNTY OF LOS ANGELES BUILDING AND SAFETY L Certified copy is filed with the county building-inspec-- FOR APPLICANT TO FILLIN BUILDING tion department ADDRESS (PRINT OR TYPE ONLY) Datef ApplicantLOCALITY • GTy NO TYPE OF APPLIANCE OR EQUIPMENT FEE l/l CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST , '.COMPENSATION INSURANCE CROSS ST ABSORPTION.UNIT, BTU " (This section need not b@ completed,if th@,Work inVOIV@d b DISTRICT NO / PROCESSED BY -T" the permit is'foE one hundred dollar"s (5 100) or less. t� ' I ceFtify that in Tlie performance of the work fo ch this AIR HANDLING U'IT,.CFM J O .permit is issued; I'shall not employ any pe any manner BOILER, BTU so as'tho/become sublect,to the Worker ' ensation Laws.' .' APPROVALS AT NSPECTOR'S SIGNATURE Date 0 Applica COMPRESSOR, BTU ROUGH NOTICE TO APPLICANT: If er making this Certificate of VENTILATION SYSTEM FINAL . t Exemption,'you.:shoul ecome, subject to the Workers' Compensation provisions of the.Labor'Code, you must forth- EVAPORATIVE COOLER V LIDATION �., wqh comply with such provisions or this permit shall be deem- ed revoked FURNACE FAU GRAVITY LICENSED CONTRACTORS DECLARATION -FLOORBTU l(70�['T f O .r . 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' WALL and Professions Code,and my license is in full force and effect. License Number J 7o Lic. Class �. O U Contr r. ��/�I�LP j�� />�V'Date O. 1: AO pm exempt under Sec. U "" Plah check fee B.BP.C. for,this•rea*s' CL Date: PERMIT ISSUING FEE,$ Z Sign r TOTAL FEE LDE E LARATION PLAN CHECK APPLICANT ,4=, C, I hereby of at I am exempt from the Contractor's License ; Law for th following reason (Section 7031.5, Business and, NAME !J j -� ,e, _ Professions Code): _ ADDRES ,,�i 4 ❑ I, as owner of the'property', or m,y'"ernployees with �����L�� s< �' Q' f.' r s• wages as their sole compensation, will do the work and ACCT. os the structure is not Intended or offered for sale(Section •• CITY , TEL ,�Bi 7044,'Business•and'Profess ions Code). OWNER NAPM I, as,owner of the property, am exclusively contracting.' �` 1 ITEMS with licensed contractors to construct the'project (Sec- MAIL /�,r tion 7044, Business and Professions Code) ADDRESS l/f N� . T'OO'L 63 . 00 CONSTRUCTION LENDING AGENCY �?d I hereby affirm that there is a construction lending agency for CITY VVIR TEL NO Nj�/3l `HECK �j�`�,iE� -the performance of•the work for which this permit is issued CONTRACTOR , CHANGE ,I 111 (Sec. 3097, Civ.,C.). ADDRESS -•• Lender's Name CITY TEL No 0000—FIJOI 5/18/90 Lender's Address I certif that I have read this a and state that'ihe STATE LIC. Q j��I•' i[I; 4 y LICENSE NO CLASS above information is.co agree Tp_comply with all County ordinances cin e laws rela4h§ to building construction,'' and here ut onze�esentatives of this County to enter upo a abo - oned property f r,inspe tion purposes. y� SEE REVERSE FOR EXPLANATORY LANGUAGE ' e of Applicant•or Agent Date ' ©s