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HomeMy Public PortalAbout4820 HALLOWELL AVE_Mechanical__ &ORKERS' COMPENSATION DECLARATION "rh eby�,yffi•:xn_that I have a certificate of consent to self APPLICATION FOR PERMIT insufls,(or 6 certificatefof Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING . or 6 certified copy thereof (Sec. 3800, Lab. C.) 76A364C e- - CE-818'(REV. 10/81) 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 / l tion department. ADDRESS (PRINT OR TYPE ONLY) . Date Applicant LOCALITY . A NO. TYPE OF APPLIANCE OR EQUIPMENT FEE / /� � �./° CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST ST COMPENSATION INSURANCE u. ' '' /"f ZS %'CD (This section need not be completed if the work involved.by ABSORPTION UNIT, BTU DISTRICT NO. P ESSED 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'CO SQtIOn La S. BOILER, BTU APPROVALS DATE NSPECTOR'S SIGNAT E Date ^Z� Applicant COMPRESSOR, BTU ) b 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 VALIDATION with comply with such provisions or this permit shall be deemed revoked. FURNACE: FAU k RAVITY 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. CL License Number �>,j ��< Lic. Class G. G �-1 , u r 09 Contractor , 10 v Date ' �� O I am exempt under Sec. 3-3# v h 2� Plan check fee 8.&P.C. for this reason � 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 NAME Professions Code): L ❑ 1, as owner of the property, or my employees with ADDRESS tt��r wages as their sole compensation,will do the work and ACCT. the structure is not intended or offered for saleSection CITY TEL. NO. 7044, Business and Professions Code). ( OWNER `�"07 _ Q..7 L fADDRESS � , 1:1I, as owner of the property, am exclusively contracting AIL )} // 1 1 IEMS with licensed contractors to construct the project (Sec- 2 G`L^ TOTAL 42- 75 tion 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY IrY. s �Lr" TEL. NO. r'f� sti; t�7 7� Ihereby affirm that there is a construction lehding agency for / the performance of the work for which this permit is issued CONTRACTOR j( "A_ � leCjG� ► — CHANGE .130 (Sec. 3097, Civ. C.). _ ADDRESS t y( Lender's Name 1l' CIT 4A, ' Cry r� TEL, �' ! X1`4 - itl� 3I Lender's Address184`f 1 AM11°y4 STATE. // 2r� ..c 'LI'C. Z ° I certify that I have read this application and state that the LICENSE NO./ -'_' 7 l CLASS 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 upon the above m ntioned pr perty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent Date WORKERS'COMPENSATION DECLARATION CEA 818(2-80) L_�I(— IJ—" UC AT 0 OO N FOR P F R M ff I hereby affirm that I have-a' certificate of consent to self insure, or a certificate of Workers"Comyensation Insurance,of a certified copy thereof(Sec. 3800, Lab.C.) Policy No. Company Certified copy is hereby furnished. COUNTY OF LOS ANGELES MOLDING AMD SAFETY Certified copy is filed with the county building inspection department. FOR APPLICANT TO HLL M BUILDING � 2, d Date p Applicant (PRINT OR TYPE ONLY) ADDRESS Z0 Lp !r CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITYax� COMPENSATION INSURANCE NEAREST p 1 yYIYL } (This section need not be completed if the work involved ARSt'RPTION UNIT, BTU CROSS ST. h�1✓ygLi`�� JT tG— O by the permit is for one hundred dollars ($100) or less.) I kG ` DISTRICT NO. PROCESSED BY 0 I certify that in the performance of the work for which this I 'AlHANDLING-UNIT,CFM ���„ permit is issued, I shall not employ any pe -on in any manner l O so as to become subject to the Worker, _omp� sati ,n Taws. I BOILER, BTU U (y APPROVALS DATE INSPEC OR'S SIGNATURE Date • �G � r' COMPRESSOR, BTU d ROUGH to NOTICE TO APPLICANT: If, after making this Certificate of1 VENTILATION SYSTEMFINAL ✓/ �� Z Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- I EVAPORATIVE COOLER with comply with such provisions or this permit shall be VALIDATION deemed revoked. IFURNACE:. FAU—� AVITY LICENSED CONTRACTORS DECLARATION FLOOR: BTU_6vfWD 10 I hereby affirm that I am licensed under provisions of Chapter HEATER: SUSPENDED UNIT 9 (commencing with Section 7000)of Division 3 of the Busi- i WALL ness and Professions Code, and my license is in full force and 4 effect. F License Number Lie.Class I{ Contractor Date I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer pian check fee 25%Of above. acting in my professional capacity (Section 7051, Bus- iness and Professions Code). PERMOT MUONG FEE $ Lie.or Reg.No. Date ' TOTAL PEIE HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT , I hereby affirm that 1 am exempt from- the Contractor's NAME 5 5 1„1 A License Law for the following reason (Section 7031.5, Busi- / ' ' ness and Professions Code): /' ADDRESS # o 0 0 0 o8 El 1, as owner of the property, will do the work and the I structure is not intended or offered for sale (S [tion CITY TEL.NO. 2 o,- 7j Q,5.0 7044, Business and Professions Code). O / OWNER . S1 J °i° ° 3 Q.5 01J I, as owner of the property, am exclusive) contracting with licensed contractors to construct the project MAIL +� � 0'9.2 3'—8'3 (Section 7044, Business.and Professions Code). ADDRESS CONSTRUCTION LENDING AGENCY CITY _ _%e „ TEL. NOj"�� -•©!f�. I hereby affirm that there is a construction lending agency I��l. for the performance of the work for which this permit is CONTRACTOR issued(Sec.3097,Civ.C.). Lender's Name ADDRESS Lender's Address CITY TEL.NO. I certify that I have read this application and state that the STATE LIC. above information is correct.I agree to comply with all CountyLICENSE NO. CLASS ordinances and State laws regulating Heating, Ventilating and Air Conditirnip„ and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE County tr ter up- . the love mentioned property for inspec/tio. � rposr'. . �( ✓ Signature of Permittee Date