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Home My Public Portal About5547-49 HALLOWELL AVE_Mechanical__ WORKER'S COMPENSATION DECLARATION 720-0046 6A364CPW9/89 ' ®� p��j�� {{//��►► I he eQlf PL�� by affirm that I have a certificate of consent to self insure, I�iQTI®Iltl or a certificate of Worker's Compensation Insurance, or a.certified HEATING VENTILATING-AIR CONDITIONING et vv a \J UUU y' copy theretf(Sec.3800 Lab. C.) 'uI Policy No. Company COUNTY OF`.LOS ANGELES -DEPT OF PUBLIC WORKS BUILDING AND SAFETY/{DIV'. Certified copy is hereby furnished. 7 / BUILDING Certified - - Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN ADDRESS, department. (PRINT OR TYPE ONLY) LOCALITY Date // Applicant NO: TYPE OF APPLIANCE'OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM'WORKERS' NEAREST " CROSS ST. `.COMPENSATION INSURANCE � - ABSORPTION UNIT,BTU ASSESSOR (This section need not be completed if the work involved by the MAP BOOK PAGE PARCEL permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFMDISTRICT NO. PROCESSED BY I certify that in the performance of the,work for which:this permit' is issued, I Shall not employ any person in any manne so as to BOILER,BTU '1 v become subject to the Workers'Compensa on Laws. (J d �y r) COMPRESSOR,BTU �D Date, Applicant U J✓ APPROVALS DATE` NSPECTOR'SSIGNATURE' VENTILATION SYSTEM ' NOTICE TO APPLICANT: If, after-making this Certificate of ROUGH Exemption,you should become subject-.to the Workers'Compensation EVAPORATIVE COOLER �y�. provisions of'the Labor Code, you must forthwith comply with such FINAL: 3-/" Gl a-f, provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY VALIDATION LICENSED CONTRACTORS DECLARATION FLOOR BTU I:hereby,affirm that I am licensed under provisions of,Chapter 9 `SUSPENDED UNIT (commencing.with Section 7000) of•DiviSion 3 of the Business and HEATER: WALL Professions Code,and my license is in full force and eff License Number j14 J Lic.Class , D o ContractoDate � (, ❑. I am exempt under Sec. Plan Check fee B.&P.C.for this reason PERMIT-ISSUING FEE $ ft-O U , Date: TOTAL FEE d Signature PLAN CHECK APPLICANT' OWNER-BUILDER,DECLARATION. _.. Z I hereby affirm that I am exempt from the'Contractor's License Law NAME D for-the following reason (Section 7031.5, Business and-Professions Code): ADDRESSn _T a - - -'`�• - I, as owner of the property, or.my employees with wages'*' t'9 04 as their sole compensation; will do the work and the CITY TEL.NO. 1 1 1,f 130 structure is not intended or offered for sale (Section 7044,. T Business and Professions Code). OWNERf :• 1 ITEMS . F1, as owner of the property,'am exclusively contracting' MAIL 'I i-A '73 = 00. with licensed contractors to construct the project (Sec- ADDRESSS tion 7044, Business and Professions Code). CHECK CONSTRUCTION LENDING AGENCY CI 9 TEL.NO: �' O I hereby affirm that there is a construction lending agency for CONTRALTO (� s D !C HANG the performance of the work for which this permit is issued _ (Sec.3097,Civ.C.). !/ ADDRESS > / WOMAN li_ia Lender's Name �rI I_1 I � ••i CITY TEL.NO. Lender's.Address STATE ,y ' LIC. I certify that I have read this application and state that the above LICENSE NO. gm CLASS '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-mentioned prope y 'r inspecti0 /p p es. ,� SEE REVERSE FOR EXPLANATORY LANGUAGE ,a 7. SIGNATURE OF APPLICANT OR AGENT DATE ' a WORKER'S COMPENSATION DECLARATION 20-0046 DPW 9/89 t�U'PL�'��®^n �� n��• 76A364C u NI u�l� UME //��7HE t herby_afficm that I"have a,certificate of consent to self insure, �l {or a-certificate of Worker s Compensation;lnsurarice, or a certifedTI �a�l GG UU _ HEATING-VEN EATING -AIR CONDITIONING` ' copy thereof(Sec.3800 Lab. C.)- Policy No. Company • COUNT:Y'OF LQS ANGELES DEPT OF PUBLIC WORKS BUILDING'AND SAFETY DIV. ECertified copy'is hereby furnished.; El ' Certified copy is.filed with the county building inspection FOR APPLICANT.TO FILL IN gDDR S department.-- '!_• r '° • '• . '(PRINT OR TYPE ONLY) - t.. - _ LOCALITY"'" % Date. APPlicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION•,FROM'WORKERS''. - COMPENSATION INSURANCE ABSORPTION UNIT,BTU NEAREST_ ' (This section-need not be completed,if the.work involved by the. „ ASSESSOR PAGE'. PARCEL permit is for`one hundred dollars-($100).or less.) AIR HANDLING UNIT,'CFM- I certify that in the performance of.the:work for which this'permi DisTRicrNo:' PROCESSED BY •. is issued, I.shall.not employ any person in any,.manner so as to BOILER,BTU ' become subject to'the Workers' Compensati Laws. ... �•. e� 11 c PRESSOR,BTU �v Liv DD_ •' VENTILATION - - - �^f COM APPROVALS DATE INSPECTOR S SIGNATURE Date�_9 c '� - Applicant TILATION SYSTEM NOTICE TO APPLICANT: If, after making this Certificate of ROUGH.' Exemption,'ybu Should become subject to the Workers'Compensation EVAPORATIVE COOLER_ provisions of the Labor Code, you must,.forthwith,comply:with such'. FINAL' provisions or this permit shall be deemed revoked.,:•r FURNACE: FAU GRAVITY 2 ' LICENSED CONTRACTORS:DECLARATION FLOOR BTU % /p �D VALIDATION ; I.hereby affirm that I,am licensed under:,provisions of Chapter 9,' SUSPENDED, UNIT (commencing with' Section 7000) of Division 3 of the,,Business and ;HEATER: WALL =` Professions Code t and my license is in full force and effec `' 71 License Number Lic.Class >' Contractore '�7 L4 p O: ❑. Plan check fee Igam exempt under Sec."'� � � -` B.&P.C.for this reason ` '• PERAAIT ISSUING FEE$ &`0 ;O Date: j TOTAL FEE Q'O L Signature d y PLAN CHECK APPLICANT .(A OWNER-BUILDER DECLARATION'_ Z I hereby.affirm that I am exempt from the Contractors License Law NAME for the following reason (Section,7031.5', Business.and'Pcofessiens , D .tI Code): ADDRESS As owner theisole compensatir on, will do the worka 'wages 0 +• Y P Y •t and the CITY TEL NO• a structure is not intended or offered for sale (Section 7044, , Business and Professions Code). OWNS with li ensedfc ntracto s-to',c nstructsthel'projecta(Sec. ADDRESS, I) I ® � the property, Y 9 I?t ° .. �G tion 7044, Business and Professions Code). CH �j.1 4,9 CC CONSTRUCTION LENDING AGENCY CITY .` r - LCL TELi,NO.. �_ Ci� . t; I hereby affirm that•there is,a con's{ruction'lending agency for / HIS h3 the performance of the work for which .this'permrt is issued CONTRACT D (Sea 3097,Civ C) Cr-t ADDRESS Lily III 3 i 1's i7.1 ',. Lender's Name CITY'' TEL.NO. ,. Lender`s'Address STATE LIC. I certify thaf l:have read this'-application'and state that the above LICENSE NO. CLASS D information is correct. I agree to comply with all County ordinances . and State laws relating to building construction,and hereby authorize represehtatives of this uTty to enter upon the above-mentioned prope ty,or-inspecgfii7rp es. �f SEE REVERSE FOR EXPLANATORY LANGUAGE SIGNATURE OF PPLICANT OR AGENT' DATE �:�"-