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HomeMy Public PortalAbout4840 GLICKMAN AVE_Mechanical__ WORKERS' COMPENSATION DECLARATION APPLICATION FOR PERMIT I hereby affirm that I"have,a certificate of consent.to self insure„cr a certificate of Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING r 'br a certified copy thereof (Sec. 3800, Lab. C.) 76A364C N boo .775 L► L/FO,E1011F-0046 DPW 9/88 Policy No. Company �y Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY l�JC7L/ Certified copy is filed with The county building inspec- FOR APPLICANT TO FILL IN BUILDING A �\tion depar ment. ADDRESS � �J I A/`J A� (PRINT OR TYPE ONLY) Date A S/=1 S,ct►�1 V Tf/U LOCALITY r �� Applicant NO.. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' I NEAREST COMPENSATION INSURANCE CROSS ST. Z-01--ld—z- AZ CSS 04 (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.) AIR HANDLING UNIT, CFM 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 become subject to the Workers' Compensation Laws. BOILER, BTU APPROVALS DATE INSPECTOR'S SIGNATURE Date pplicant COMPRESSOR, BTU 7 ®� ROUGH A 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 VALIDATION with comply with such provisions or this permit shall be deem- ed revoked. FURNACE: FAU RAVITY LICENSED CONTRACTORS DECLARATION FLOOR U I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED—UNIT. (commencing USPENDED UNIT— (commencing with Section 7000)of Division 3 of the Business WALL and Professions Code,and my license is in full force and effect. P 2 ,N� �-S i� ®v IG C- 7-C/ CL a License Number + �Z Lic. Class 2-a ® p O Contractor KC M 66HA NI <A L 0 ❑ I am exempt under Sec. U Plan check fee ,� w B.&P.C. for this reason. ,. n- PERAAIT ISSUING FEE $ Z Signature Date: _ TOTAL FEE ® `" OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT I hereby affirm that 1 am exempt from the Contractor's License u Law for the following reason (Section 7031.5, Business and NAME Professions Code): F1 1, as owner of the property, or my employees with ADDRESS wages as their sole compensation,will do the work andri�-'t-'' - ` the structure is not intended or offered for sale Section CITY /TEL. NO. 7044, Business and Professions Code). OWNER � r/i F] ��A I, as owner of The property, am exclusively contracting 0 F with licensed contractors to construct the project (Sec- MAIL �r ADDRESS //� AL, -- tion 7044, Business and Professions Code). L / I IJ I HL ` a € CONSTRUCTION LENDING AGENCY CITY e` O 7 /p OTgL. NO. I hereby affirm that there is a construction lending agency for' `' the performance of the work for which this permit is issued CONTRACTOR ® E 13t (Sec. 3097, Civ. C.). ; Nie �- �O . _aif iii -- Lender's Name ADDRESS (L- GC S �9 CITY rt Cg EL. NO. i� __ _ ' 1' /;=,'-t_i Lender's Address STATE LIC. I certify that I have read this application and state that The LICENSE NO. ���� J Z' CLASS above information is correct. I agree to comply with all County ordinanc frhd State laws relating to building construction, and her y authorize representatives of this County To enter upon T o e-men toned properly for inspe tion puposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applic nt or Agent Date ©s WORKERS'.COMPENSATION DECLARATION APPLICATIONI hereby[ affirm that I have-a certificate of consent to self FOR PERMIT • insure, or a Eertificate of Workers' Compensation Insurance, BEATING - VENTILATING - AIR CONDITIONING ;)r a cer Ified-.copy thereof.(Sec. 3800, Lab. C.) 76A364C Policy No. Co vt©O 7;rr2- G4 C L/��,���� 20-0046 DPW 9/88 mpany ❑, 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 tiondepar ment. (PRINT OR TYPE ONLY) ADDRESS Date �� Applicant S� ✓SR��'/�7� LOCALITY NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERT FICATE OF EXEMPTION FROM WORKERS' NEAREST COMPENSATION INSURANCE CROSS ST. LAOG✓I�Fof- A 2-C/Sh (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.) I certify that in the performance of the work for which this AIR HANDLING UNIT, CFM permit is issued, I shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws. BOILER, BTU APPROVALS DATE INSPECTOR'S SIGNATURE Date Applicant COMPRESSOR, BTU ROUGH 2-1L d NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL &-2-S/ 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 LICENSED CONTRACTORS DECLARATION , FLOOR TLI I hereby affirm that 1 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. t n / a���.5, �UrCeT� I!i 3- License Number 2-Lic. Class 2 , CL O GG` t�- u ContractorY``�' M� e[ ❑ I am exempt under Sec. o Plan check fee U Lu B.&P.C. for this reason. Z PERMIT ISSUING FEE $ Date: TOTAL FEE Signature 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 NAMEf�/,A�L�X `Je�n�s'd4/� %/T�L/1� pop :- Professions Code): j ❑ 1, as owner of the property, or my employees with ADDRESS I Z�� wages as their sole compensation,will do the work andthe structure is not intended or offered for sale(Section CITY C7 TEL. NO. �t�cA P(A r o� = a E f{ 7044, Business and Professions Code). OWNER ❑ I, as owner of the property, am exclusively,contracting C �� with licensed contractors to construct the project (Sec- MAIL v� � A vim_ IRL 1 00 tion 7044, Business and Professions Code). ADDRESS 1,9 CONSTRUCTION LENDING AGENCY CITY TEL. NO. �d 1r `= {=="• w �'•1i ©s 90,0/ 213 71 3 1 hereby affirm that there is a construction lending agency for r sa,; Y " the performance of the work for which this permit is issued CONTRACTOR ./, L �G CO Ittl,Jt G MXCly,4 (Sec. 3097, Civ. C.). �s ADDRESS /Z3� �• �f�T;A CZ-AR S %• 5r / {{_{I;1{-i_{i{1; s `5/o Lender's NameA5/or Lender's Address CITY /Te64P1A I C7o, TEL. NO. =' Fr TATEJ j� I certify that I have read this application and state that the SCENSE NO. /�� 2 CLASS above infor tion is correct. I agree to comply with all County orFha)utoriz�representatives aaws relating to building construction, anof this County to enteuen d pro rty for inspectio pure ses. -�`' SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of ApI nt or Agent Date ©s WORKERS'.COMPENSATION DECLARATION P P L I CAT I®N 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 D a certified copy thereof.(Sec. 3800, Lab. C.) 76A364C C110 7 7� Q a� ®P N/ 40-0046 DPW 9/88 Policy No. o pans I �s Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY y Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING Tion dep rtmenT. ADDRESS A L S� Sf1N�I i J (PRINT OR TYPE ONLY) LOCALITY Date Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CER IFICATE OF EXEMPTION FROM WORKERS' I NEARESST. G�JG✓�,� ZtJjf� COMPENSATION INSURANCECROSS (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.) I certify that in the performance of the work for which this AIR HANDLING UNIT, CFM permit is issued, I shall not employ any person in any manner so as To become subject to the Workers'Compensation Laws. BOILER, BTU APPROVALS DATE INSPECTOR'S SIGNATURE Date. Applicant COMPRESSOR, BTU ell ROUGH /Z_/1__-11Z � d 47_12 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 VALIDATION with comply with such provisions or this permit shall be deem- ed revoked. / F RN CE: F A U BTU R VITY _ LICENSED CONTRACTORS DECLARATION 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. Z ✓`7L/ ,�f O� L �� '9V �7 pC CJa License Number // 1 Z Lic. Class �' ® o Contractor C MSC IA rel t�� _ 0 ElI am exempt under Sec. 0 Plan check fee LU BAP.C. for this reason. a PERMIT ISSUING FEE $ Z Signature Date: _ TOTAL FEE 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 Professions Code): r I, as owner of the property, or my employees with ADDRESS 12 5- e- �!' � eZAjeA .51 46 wages as their sole compensation,will do the work and � �P� 9 The structure is not intended or offered for sale(Section CITY `C)0JEL. NO. 7044, Business and Professions Code). OWNER ,� " 6`"`i`l f CN� Q/ V " I, as owner of the property, am exclusively contracting _ I I'w;e; with licensed contractors To construct theec- MAI S ect j roL P ( 3 � v .� tion 7044, Business and Professions Code). ADDRESS .� "� ;5TA 6 1 00 CONSTRUCTION LENDING AGENCY CITY Coes q– S �,'pTE�. No.Z Q I hereby affirm that there is a construction lending agency for _ – the performance of the work for which this permit is issued CONTRACTOR k c— M/i C f1-An f1 e 5- e© i_!E€=3)'= • :,_- (Sec. 3097, Civ. C.). ADDRESS f 2� Ar. /� CL�2A S_ l Lender's Name n CITY f�P_(,f10/jq 1046 TEL. NO. <-? 7 Sal ( IJ'"1=:,41� Lender's Address STATE q LIC. ��r; ! `�1,0°'�,i 1 certify that I have read this application and state that the LICENSE NO. S �l / � CLASS 'Z j`S' above information is correct. I agree to comply with all County ordinanc Sd Stare laws relating to building construction, and he authorize presentatives of this County to enter U a-m n,oned property for inspectio purpo es. j ,,,rte SEE REVERSE FOR EXPLANATORY LANGUAGE j Signature of Appl nt or Agent Date ©s "-WORKERS' GOMPENSATIO'N DECLARATION APPLICATION FOR PERMIT I hereby affirm that I have a certificate oT consent to self insure, pr a.certificate of Workers"Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING .or a certifies!copy thereof,(Se . 3800, Lab. C.) 76A364C _ 20-0046 DPW 9/88 Policy No.Af 94p �>��� �rA ❑ 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 (-J - / tion dep rtment. ADDRESS Sj O-P&4 �_ 7 /�!E P�r�H'a� (PRINT OR TYPE ONLY) LOCALITY C./ Date Applicant ^ V ��,I �� �! , T NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CER IFICCOMPENSATION INSURANCE ORKERS' NEAREST 2 �� CROSS ST. dG✓� (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.) I certify that in the performance of the work for which this AIR HANDLING UNIT, CFM permit is issued, I shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws. BOILER, BTU APPROVALS DATE INSPECTOR'S SIGNATURE Date Applicant COMPRESSOR, BTU ©v� /7 — ROUGH Z-Jl �/��� NOTICE TO APPLICANT: If, after making this'Certificate of VENTILATION SYSTEM FINAL ��/ i�t� 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 d8A0Y LICENSED CONTRACTORS DECLARATION ( FLOOR BT 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 L Li/�c.. Class 4- O Contractor mee-HA A�/`�'D°ate / , V ❑ ISG I am exempt under Sec. o Plan check fee w B.&P.C. for this re so /,-I o �� Z PERMIT ISSUING FEE $ Signature TOTAL FEE 14, 1 OWN -BUILDER D CLARATION 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 �� �! �/�S S � SAIV J I 'rOVC)/� j Professions Code): Irli, as ADDRESSAZ ❑ I, as owner of the property, or my employees with 5'A Al rA GGAf-A. wages as their sole compensation,will do the work and =TE the structure is not intended or offered for sale(Section CITYRG'���/a �ICJ�� TEL. NO.�I�i j 751.'77 0- ; is;= } 7044, Business and Professions Code). OWNER ❑ I, as owner of theproperty, am exclusive) contracting I C F-1 A�� pa Y 9 with licensed contractors to construct the project (Sec- MAIL le tion 7044, Business and Professions Code). ADDRESS Y (i /?%- AV— i:,HAr(;SE CONSTRUCTION LENDING AGENCY CITY e �� � �p �t,�10. 213 �'©Z ®� O I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued CONTRACTOR �J,� C� ii "a_:`a z y i= ' (Sec. 3097, Civ. C.). MFC�-IA /S� L r; :}I_t_ _ii 11 3 t:' =f 3 ADDRESS SA Z S F- �T/a CL/-i f7 S / t Lender's Name ,�I+ JQ s1 Lender's Address CITY AP-e--A®1- 9JCJ(9 L. NO. I certifythat I have read this application and state that the STATE ry LIC. 2 PP LICENSE NO. / �� Ze" CLASS above i formation is correct. I agree to comply with all County ordina s nd State laws relating to building construction, and r authorize representatives of this County to enter upo th a ve-mery(ioned pro erT for inspection purp es. Y"� �� O SEE REVERSE FOR EXPLANATORY LANGUAGE Sign Pure of Appl' ant or Agent D to ©s