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Home My Public Portal About9026 HERMOSA DR_Mechanical__ -WORKER'S thatICOMPENSATIONDECLARATION , 20-0046DPW9/89 APPLICATION FOR PERMIT LIME GREEN, _ 0-00 4C I hereby.effirnilhat ,'have a certificate of consent to self insure, 76A3 • or a certificate of Worker's Compensation Insurance, or a certified - - HEATING -VENTILATING-AIR CONDITIONING copy thereof(Sec.3800 Lab. C.) Policy No. Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND.SAFETY DIV. LI Certified copy is hereby furnished :+ ❑ Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN BUILDING g6216, A. department. (PRINT OR TYPE ONLY) ADDRESS Cl vl�Y� -Date Applicant _ - NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY CERTIFICATE OREXEMPTION FROM WORKERS' NEAREST ` COMPENSATION INSURANCE CROSS ST. • 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($100)or less:) AIR HANDLING UNIT,CFM eRT NOPROCESSED BVETIC ` I certify that in the performance of the wor 'for which t is permit is issued, I shall not employ any person IT so as to BOILER.BTU I become subject to the Workers'Co o La �0Gf�LsC..GtaC-�,� COMPRESSOR,BTU r r PPPflOVPl$ GATE INSPECTOR SIGNATURE Date-�� Plic t VENTILATION SYSTEM NOTICE TO PLld become N, eking this Certificate of ROUGH Ex visions of should r Code, you subject,to lhe,Workers'Compensation such _ _ EVAPORATIVE COOLER _ provisions of the Labor Code, you musCforihwith comply'witn such - -- - _ FINAL _ S• _ provisions or.this permit shall be deemed revoked. FURNACE: . FAU GRAVITY - •LICENSED CONTRACTORS DECLARATION - FLOOR BTU VALIDATION I hereby affirm that I'am licensed under provisions of Chapter 9 SUSPENDED—UNIT— WALL USPENDED UNIT_ ` (commencing with Section 7000)of Division 3'0l the Business and HEATER: WALL Professions Code,and my license is in full force and effect. License Num Lic.Class / _f �- 1k- CdnVaq Date ) ) a O ❑ I am exempt under Sec. - Plan Check fee - - U cc B.BP.C.for this reason PERMIT ISSUING FEE$ tf...��, �. - "• O Date:. _ TOLU TALtFEE _ 8r�I.[�. .• U Signature � '" - - -• d 3307 PLAN CHECK APPLICANT - .1 ITEMS OWNER-BUILDER DECLARATION t;" . - ` Z I hereby affirm that I am exempt from the Contractor's License Law NAME1C U �t '_• , - - -• TOTAL + �'7 for the following reason (Section 7031.5, Business and Professions LLLL��77"'�� •A - r 82 Code): ADDRESS hI - __ _ t HE�.K 82.t7 ❑ I, as owner of the property, or my employees with wages - l^A �/ /l L�7 CHECKCHANG •Off , as their sole compensation, will do the work and the CITU Q•/-�/ 7 L�TEL,NO. /t 'VG•� . . - structure is not intended ocoffered for sale (Section 7044, �t �+ �' - - Business and Professions Code). OWNER �"7 L..f/�PCi ..�'s�'� e `-'T-- i l ❑ I, as owner of the property, am exclusively contracting- n - -y 1}{]i'!9}-Q�fOy` I16•I 92 MAIL-' qN� with licensed contractors to construct the project (Sec- ADDRESS nll �"'? tion 7044, Business and Professions Code). rt +. CONSTRUCTION LENDING AGENCY CITY .1 TEL'NO. / - I hereby affirm that there is a constriction sperlending agency for CONTRACTOR PON ' the performance of the work for which this permit Is issued Lit Pi - (Sec.3097, Civ. C.). • `r ty' ' ADDRESS . _ V G - - -Lender's Name ' CITY TEL.NO. "- Lender's Address STATNSE UC. _ I certify that I have read this application and state that the above LICE E NO. 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 - - properly for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE - SIGNATURE OF APPLICANT OR AGENT DATE LL WORKER'S COMPENSATION DECLARATION 20 W9/89 APPLICATION FOR PERMIT � � � �� 6A36,1C A364C I hereby..off irr that 1 have a certificate of consent to self insure, or a certificatel'�f Worker's Compensation in .,surance, or'a certified HEATING- VENTILATING-AIR.CONDITIONING.. J� copy thereof(Sec.3800 Lab.C.) Iff A -42� S�-�b � PolicNo. Company]ZG3 d . y COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV. Certified copy is hereby furnished. ❑ . . BUILDING / Certified copy'is filed with the county building inspection FOR APPLICANT TO FILL'IN, ADDRESS Qf CZ �OS•� a department. - - _ (PRINT OR TYPE ONLY) Date ��6'�J� Applicant ' �f d LOCALITY NO. TYPE OF APPLIANCE OR EQUIPMENT FEE .. -- _ - _ _ _.. ._ NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS ' CROSS ST. COMPENSATION INSURANCE ABSORPTION UNIT,BTU - - - (This section need not be completed it the work involved by the' _ ASSESSOR "rant is for one hundred dollars $100 or less. - MAP BOOK PAGE el PARCELQ/1Q P, ( ) ) AIR.HANDLING UNIT,CFM GTrICT No. PRMESSF.er I certify that in the performance of the work-for which this permit is issued, I shall not employ any person.in any mentor so as to BOILER,BTU become subject to the Workers'Compensation Laws, �� COMPRESSOR,BTU 2 B"LX-Es G - Dale Applicant APvnovAlS FATE INSPE 's SIGNATURE PP VENTILATION SYSTEM ,NOTICE TO APPLICANT: If, after making Ahis Certificate of _ - ROUGH Exemption;you should become yoursubject to t forthwith CiS Compensation -,EVAPORATIVE COOLER - » _ -. -. __ .e FINAL "provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY LICENSED CONTRACTORS DECLARATION „ FLOOR BTU c. O VALIDATION !.hereby..affirm,thatd..am-licensed under.provisions,of.Chapter 9. __.�: y 'SUSPENDEDT UNI , (commencing with Section 7000)of Division 3 of the Business and 'HEATERWALL Professions Code, and my license is infull force and effect. Ut— , - > License Number Lia Class` /O el�A O ACCT.: a Contractor�yze Date ❑ / Plan checklee 3303 97.300 I am exempt under Sec 1 ITEM a� BAP.C.for this reason PERMIT ISSUING FEE$11 V. D TOTAL 'm 300 '- Date: TOTAL FEE U Signature CHECK 97.30 EL U' OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT CHANGE .00 Z I hereby affirm that I am exempt from the Contractor's License Law 'NAME Poo. , for the following..reason (Section 7031.5, Business and Professions ' Code): - _ ADDRESS 000[0[-0001 9/ 6/95 t El1„as owner of the properly, Or my employees with wages 2164 1 AM 9:19 as their sole compensation, will do the work and the CITY TEL.NO. structure is not intended or offered for sale (Section 7044, Business and Professions Code). OWNER ` ❑ I, as owner Of the property, am exclusively contracting MAIL ' with licensed'contractors to construct the project (Sec- ADDRESS ' tion 7044, Business and Professions Code). - - - CONSTRUCTION LENDING AGENCY iCIN TEL.NO. Aleby affirm that there is a construction lending:agency for CONTRACTOR �,/� �,p /l e performance of the work for which this permit Is issued �• //ter //l (Sec.3097,Civ.C.). ADDRESS 62 - Lender's Name CITY j 1.� �, TEL.NO. S7J' (� Lender's Address STATE tom` //" / LIG • - ' I certify that I have read this application and state that the above LICENSE NO. CLASS C(� 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 , property for inspection purposes. . SEE REVERSE FOR EXPLANATORY LANGUAGE T SIG ATURE OF AP IC. IT OR AGENT DATE