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Home My Public Portal About5519 HILTON AVE_Mechanical__ 76A WflitXERS'COMPEN SATION DECLARATION -81C CE 1 APPLICATION IO1tl Ir OR PERMIT Iie.'�„by affirm that I have a certificate of consem to self CE 81H(280) insure, or a ;ertificale of Workers'Compensation Insurance,or HEATING-VENT ILATI NG-AIR CONDITIONING u certified copy thereof(Sec. 3800, Lab.C.) Policy No. Company ❑ Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY ❑ Certified copy is filed with the county building inspection -department. FOR APPLICANT TO FILL IN BUILDING Date Applicant (PRINT OR TYPE ONLY) ADDRESS CERTIFICATE OF EXEMPTION FROM WORKERS' NO. LOCALITY TYPE OF APPLIANCE OR EQUIPMENT FEE COMPENSATION INSURANCE' NEAREST y (This section need not be completed if the work involved ABSORPTION UNIT, BTU_ CROSS ST. 0 by the permit is for One hundred dollars (SIOB) or less.) DISTRICT NO. PROCESSED BY L) I certify that in the performance of the work for Which this AIR HANDLING UNIT,CFM (� Cr permit is issued. I shall not employ any person in any manner V so as to become subject to the Workers'Compensation Laws. BOILER,BTU // / (� APPROVALS DATE INSPECTOR'S SIGNATURE LU Date_4J_—_2&_ Applicant •f.�r% C� " / COMPRESSOR, BTU.3a/-�A / SJ ROUGH _ + IL NOTICE TO APPLICANT: e after making this Certificate of Z VENTILATION SYSTEM FINAL y•t'.Q Exemption, you should become subject , the Workers- ( !� v Compensation provisions of the Labor Code, you must forth- t with Comply with such provisions or this permit shall be EVAPORATIVE COOLEfj/ V LID 11ION deemed revoked. FURNACE: FAU t—/ G9 VITY .LICENSED CONTRACTORS DECLARATION FLOOR: BTU_ �(\ I hereby affirm that 1 am licensed under provisions of Chapter HEATER: SUSPENDED UNIT -tf 9 (commencing with Section 7000)of Division 3 of the Busi- WALL ness and Professions Code, and my license is in full force and effect. '^—r, License Number��y/ 7— Iiia Class— cZ� /1 Contractor. Date ❑ I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer Plan Check fee 25%Of above. acting in my professional capacity (Section 7051. Bus- iness and Professions Code). PERMIT ISSUING FEE $ Q Lic.or Reg.No. Date TOTAL FEE 3 Q HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT 1 hereby affirm that 1 am exempt from' the Contractor's NAME �_��/vC� License Law for the following reason (Section 7031.5, Busi- nessandProfessionsCode): ADDRESS ❑ 1, as owner of the property, will do the work and the - -+p: r-I structure is not intended or offered for sale (Section CITY TEL.NO. ,!,'ZI �,p�•)�� 7044. Business and Professions Code). OWNER �j ❑ I, as owner of the property, am exclusively contracting /Z-/ C c/� with licensed contractors to construct the project MAIL fI�!Y.. 30 m 50 (Section 7044, Business and Professions Code). ADDRESS f/xj C /C'— —13 ' CONSTRUCTION LENDING AGENCY CITY TEL.NO./ 1 hereby affirm that there is n construction lending agency _C CHAdGE ,00 for the performance of the work for which this permit is CONTRACTOR issued (Sec. 3097.Civ.C.). - Lender's Name rADDSS ® _ y Lender's Address �� •l_I_L_l�l_Lfl 4/21fGS TEL.NO. CI• 1 certify that I have read this application and state that the LIC. � Aht ).UI-I above information is correct. 1 agree to comply with all County E NO.. 4 CLASS ordinances and State law's regulating Heating,Ventilating and Air Conditioning, and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE County to enter upon the above-mentioned property for insp . uses. Zi/ Signature of Permittee Date 46 WORKER'S hveacertificate COMPENSATION DECLARATION 7636,IC W9.39 APPLICATION FOR PERMIT �gGREEN 0-004C I hereby affirm that I have a certificate of consent to self insure, v.r or a certificate of Worker's Compensation Insurance, or a certified HEATING - VENTILATING-AIR CONDITIONING [bull copy thereof(Sdc.3000 Lab. C.) Policy No. Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV. ❑ Certified copy is hereby furnished. ❑ Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN BUILDINGftif I�/, y' cis , /'per PRINT OR TYPE ONLY ADDRESS W Jj e. " ci M department ( j Date ApplicantLOCALITY NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION 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 Cfpp PAGEQQ PARCEL4�9/41" permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM nISTPILT 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 manner so as to BOILER,BTU p become subject to the Workers' Compensation Laws. COMPRESSOR.BTU APPROVALS GATE INSPELiOR'$$IGNANRE Date Applicant VENTILATION SYSTEM NOTICE TO APPLICANT: It, after making this Certificate of ROUGH Exemption;you should become subject to the Workers' Compensation EVAPORATIVE COOLER provisions of the Labor Code, you must forthwith comply with such FINAL------- provisions INA provisions or this permit shall be deemed revoked. FURNACE: FAU Gyk/ IT / LICENSED CONTRACTORS DECLARATION / FLOOR BTU �_ a !O/O VALIDATION I hereby affirm that I am licensed under provisions of Chapter 9 BEATER: SUSPENDED—UNIT— (commencing USPENDEe UNIT_(commencing with Section 7000) of Division 3 of the Business and WALL Professions Code, and my license is in full force and effect. a ac:L.r.,r License Number Lic.Class A �`S,�-.e� `.]QJ 141 J i } Contractor Date 1 I{E Ij