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Home My Public Portal About9810 HOWLAND DR_Mechanical__ WORKER'SCOMPENSATION DECLARATION 406 DPW 9/99 APPLICATION FOR PERMIT LIME GREEN; 2 hereby ahave a c "Nffirm that 1 have a certificate of consent t0 set Linsure. 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. ❑ Certified copy is hereby furnished. - 71 Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN ADORE99 department. (PRINT OR TYPE ONLY) O p Date - Applicant - LOCALITY NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST COMPENSATION INSURANCE _ CROSSABSORPTION UNIT,BTU ASSESSOR G �j p (This section need not be completed if the work involved by the t MAP BOOK 6�p PAGE PARCELQO permit is for one hundred dollars(5100)or less.) I AIR HANDLING UNIT,CFM S^d�0 olmflla No. Pflocassa0 ev 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 a n become subject to the Workers'Compensation Laws. COMPRESSOR,BTU ' APPROVALS OATS INSPEC R's 51GNAIDPE Date Applicant /� VENTILATION SYSTEM /� NOTICE TO APPLICANT: If, after making this Certificate of ROUGH Z Exemption,you 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. 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 effect. License Number Lic.Class l Contractor Date 0 U F-1 Plan check fee I am exempt under Sec: - _ B.BP.C.for this reason PERMIT ISSUING FEE $ 2't 7S 0 Date: TOTAL FEE C a __-. --r ;•r W Signature OL PLAN CHECK APPLICANT •_, rn OWNER-BUILDER DECLARATION Z I hereby affirm that I am exempt from the Contractor's License Law NAME - for the following reason (Section 7031.5, Business and Professions , A' w t �� Code): ADDRESS 91 I, as owner of the property, or my employees with wages as their sole compensation, will do the work and the CI L T arh.0 O r• -- structure is not intended or offered for sale (Section 7044, o - Business and Professions Code). OWNER ❑ I, as owner of the property, am exclusively contracting MAIL I - with licensed contractors to construct the project (Sec- ADDRESS -•--- tion 7044, Business and Professions Code). .✓ y.�' CONSTRUCTION LENDING AGENCY CITY, _ r TEL NO. f^ _ �� - - hereby affirm that there is a construction lending agency for 'CONTRACTOR the performance of the work for which this permit Is issued (Sec.3097, Civ. C.). - ADDRESS - Lender's Name - CITY TEL.NO. - Lender's AddressSTATE LIG L ._ . I certify that I have read this application and state that the above LICENSE NO. CLASS information is correct. 1 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 for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE - h'IDNAT➢REE OF APPLICANT OF AGENT fDAy WORKFRS'COMPENSATION DECLARATION 76A364C APPLICATION I�1� py p� I� 1� PERMIT I hereby affirm that I have a' certificate 0t,cc':ept-b Self CE,-818.(2-80) A If� I(– L IC A 1 I O 1 tl Ir o R If� E R M IT insure, or a certificate of Workers'Compensation Insurance,or HEATING-VENTILATING-AIR CONDITIONING a certified„opy t ,of(Sec. 3800, Lab.C.) Policy Nc Com pany_�RlK+'�"'^r Cr Certified Copy is hereby furnished. COUNTY OF LOS ANGELES 7fBUILDING AND SAFETY Certified copy is filed with 'h o. Rh'bt . g inspection p ENO. TYPE R APPLICANT CANT TO FILL IN ADDRESS -`C`�y �jNfJLLCIfU Date Applicant _ - _._ _ - (PRINT OR TYPE ONLY) 01 LOCALITY C �( r CERTIFICATE OF EXEMPTION FROM WORKERS' APPLIANCE OR EQUIPMENT FEE /^�,�/COMPENSATION INSURANCE NEARESTCROSS ST. � �./� CL(This Section need n0[ b¢ completed If [he work involvedION UNIT, BTU by the permit is for one hundred dollars (SIOO) or less.) DISTRICT NO, PROCESSED BV ,� f..I1 certify that in the performance of the work for which thisDLING UNIT,CFM y W permit is issued. I shall not employ any person in any manner O so as to become subject to the Workers' Compensation Laws. BOILER, BTU APPROVALS DATE I INSPECTOR'S SIGNATUR E W Date Applicant COMPRESSO R,BTU ROUGH 6 — _ y NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEMZ Exemption, you should become subject to the Workers' FINAL' —i Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER I4/ VALIDATIONV with comply with such provisions or this permit shall be - �OS deemed revoked. FURNACE: FAU— GRAVITY— LICENSED RAVITYLICENSED CONTRACTORS DECLAR ATION FLOOR: BTU — 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- WALL ness and Professions Code, and my license is in full force and effect. License Nur t r Lia Cl..—'V Contractoul Date ElI am exempt from the licensing requirements as 1 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 S Q jC Lie.or Reg.No. Date TOTAL FEE HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT 7-f� �•. I hereby affirm that I am exempt from the Contractor's NAME •�K ,/- 1-7�L[,� License Law for the following reason (Section 7031.5, Bus.- a`/rt,�`r �4 6 7.21A ness and Professions Code): ADDRESS�'a)t ' t::.A'17j�-� T� El I, as owner of the property, will do the work and the A #�o o 010 0 8 structure is not intended or offered for sale (Section CITYE7r71 TEL.NO. ��.♦ Z , 7044, Business and Professions Code). tttFFF "'""TTG OWNER 2I 1 0.0 6.0,0 r_1 / v� �Gr.as owner of the property, am exclusively contracting C�'f/ .� 0 0 ,e with licensed contractors to construct the project MAILlo,o o I (Section 7044, Business and Professions Code). ADDRESS 9 � ��/ 0•8,'z•,Z_813 CONSTRUCTION LENDING AGENCY CITY //t/y/7C�� TEL. NO. P�r�•'7¢�p/ I hereby affirm that there is a construction lending agency rtrLG / �(Y for the performance of the work for Which this permit is CONTRACTOR issued (Sec. 3097,Civ.CJ. -4 Lenders Name ADDRESS X753– ` Q Lender's Address CITY TEL TEL. NO. •7[�—I' I certify that I have read this application and state that the STAT 6 LIC. �I above information is correct. I agree to comply with all County LICENSE NO. � CLASS ordinan es .�d State laws regulating Heating. Ventilating and AirC ,r ng,and . ereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE Cour t n1 ter F t, the above-mentioned progeny for iusr put o .tore of Permittee Date