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HomeMy Public PortalAbout9517 GIDLEY ST_Mechanical__ WORKERS" CO"PENS'nON DECL&PA1ONto, APPLICATION FOR PERMIT Insure 'a tertlfkdie-of Works ��ompeonsatlon eln>luranm�. '� 1W a certified copy tf ereo(rJSec 3880, Lab. C.) 7_Z%M C HEATING - VENTILATING - AIR CONDITIONING 20-0646 DPW 9/88 Policy No Company ❑ Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY c�+ ElCertified copy Is filed with the county building Inspec- FOR APPLICANT TO FILL IN ADDRESS� tlon deportment. _ (PRINT OR TYPE ONLY) Data Applicant LOCALRY NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST COMPENSATION INSURANCE CROSS Si. (This-sectlon rwed not be comple+fed if the work imohre-d by ABSORPTION UNIT, BTU D[SrRV-7 NO. BY the permit Is For one hundred dbllars (;10D) or less.) - /�(� I certify that In the performance of the work foe which this AIR HANDLING UNR, CFM (�d permit Is Issued, I shall not empI any Person In any manner "LER, BTU so as to become subject to the ors Compen cal Laws. APPROVALS DATE N&PECT6RS stc�w,TURE 14 Date CbNPRESSOR, BTU ROUGH ` Applicant NOTICE TO APPLICANr IOSY T: If, aftemakln this Certificate of VENTILATION SYSTEM FINAL Exemption, you should become subject to the Workers' Compensatlon provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION with compI with such provisions or this permit shall be deem- ed revoked. FURNACE: FAU GRAVITY t t . LICENSED CONTRACTORS DECLARATION ROOK BTU l/ I hereby affirm that I dm Ikensed under provisions of Chapter 9 HEATEf: SUSPENDEDUNIT— (commencing with Section 7000)of Division 3 of the Business WALL and ProfeaiIons Code,and my license Is In full force and effed rf (:2-364 -7 a Ucense Nu c. Class , O Contrct aor a �� Im ❑ I am exempt under Sem rj Plan check fee W B.BP.0 for this reason PERMIT ISSUING FEE $ 'n Date: Z TOTAL FEE Signature OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT I hereby affirm that I am exempt from the-Contractor's License r+ , and NAME Law for the following reason (Section 7031.5, Business �^ N ( p 1 Professions Code): ❑ I, as owner of the property, or my employees with ADDRESS .?— ACCT.* wages as thglr sole compensation,will do the work and the structure Is not Intended or offered for sale(Section CITY TEL NO. M7 41.UC 7044, Business and Professions Code). OYfNER1 ITfJ'tS ❑ I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec- MAIL MAL 4 1 � 01D tion 7044, Business and Professions Code). ADDRESS CONSTRUCTION LENDING AGEN(Y CITY TEL r TF1 NO. b(^�()s� �S1 �J I hereby affirm that there Is a construction lending agency for the performance of the work for which this permit Is Issued QDNT-RACTOR � ��I k.:7 U M , .0I (Sec. 3097, Clv. C_). ADDRESS Q '7 Lenders Name 1 11/20/$9 CITY TEL NO. Lenders Address 1. AmiNi1 C. I certify that I have rood this application and state that the �ACES NO {� UCLASS above Information Is correct. I agree to comply with all County / ordinances and State laws relating to building construction, - d hereby authorize representatives of this County to enter u nth•abovb-ment ed property for Inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE nature Applicant or Agent Date �s WORKERS' COMPENSATION DECLARATION APPLICATION FOR PERMIT I hereby affirm that I have a certificate of consent to self insure, or a certificate of Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING or a certified copy thereof (Sec. 3800, Lab. C.) 76A364C 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 �—f 1 tion department. (PRINT OR TYPE ONLY) ADDRESS T J / Date Applicant LOCALITY Yo;(. NO. TYPE OF APPLIANCE OR EQUIPMENT FEE Y CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST COMPENSATION INSURANCE CROSS ST. 7C '!pl J�'J (This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO. PROCESSED BY the permit is for one hundred dollars ($100) or less.) CFM I certify that in the performance of the work for which this AIR HANDLING UNIT, permit is issued, I shall not employ any person in any manner ` so as to become subject to the W6?kers' Com.pensatiiti Laws. BOILER, BTU APPROVALS DATE INSPECTOR'S SIGNATURE S I r COMPRESSOR, BTU , '�'W ( ROUGH Date pplicant NOTICE TO APPLICA T: If, after makin 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 VALIDATION with comply with such provisions or this permit shall be deem- ed revoked. FURNACE: FAU I GRAVITY LICENSED CONTRACTORS DECLARATION FLOOR BTU ' 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. fi- 3`_ - d License Nur�er�7} (a - `"� Lic. Class (CJ 4 , V 1 a !! J U6 Contractor '"' ' !Date 1`Z U6 El I am exempt under Sec. >_ Plan check fee ad B.&P.C. for this reason PERMIT ISSUING FEE $ Date: O TOTAL FEE Signature OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT F— I hereby affirm that I am exempt from the Contractor's License polo for the following reason (Section 7031.5, Business and NAME i ;_.y< y ', ,� Professions Code): F1 1,I, as owner of the property, or my employees with �`� v 7-y', 7°'t wages as their sole compensation,will do the work and CITY- TEL. NO. J �t' • � the structure is not intended or offered for sale(Section 7044, Business and ns e). OWNER ❑ with lice s dner fthecontra°torsttooco sttrructsthelprojectacting (Sec-- AMAIL DDRESS Mj J i l tion 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY CITY TEL. NO. I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued CONTRACTOR ( , (Sec. 3097, Civ. C.). ADDRESS Lender's Name CITY TEL. NO. Lender's Address I certifythat I have read this application and state that the STATE LIC. PP LICENSE NO. ..,� ��"� �"/ CLASS 2 above information is correct. I agree to comply with all County ordinances and State laws relating to building construction, t,d hereby authorize representatives of this County to enter upPn the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE ignatureApplicant or Agent Date ©s