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Home My Public Portal About6262 IVAR AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION /p� j� /p� �p FOR (�2 j�(�/� I'herehy�affifm that 'I have a certificate of consent to self w�u ��w��OIIV l�Ol1� I!"LS11u11V11�� insure,'or a certificate of Workers'Compensation Insurance, "C E-81 MATING VENTILATING AIR CONDITIONING or-ea certified copy thereof (Sec. 3800, Lab. C.) C 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 tion deportment. (PRINT;OR-TYPE ONLY) ADDRESS Date Applicant LOCALITY NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST COMPENSATION INSURANCE CROSS ST.' (This section need not be completed if the work ABSORPTION UNIT, BTU involved by DISTRICT NO. PROCESSED 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 (�OY permit is issued, I shall not employ any person in any manner BOILER, BTU so as t0 ecome slDblect to the Wo C6 COm pensation Laws. APPROVALS DATE INS E R'S SIGNATURE i Date Pplicon COMPRESSOR, BTU ROUGH D✓ i NOTICE T APP I NT: If, df aking 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 VALIDATIO with comply with such provisions or this-permit shall be deemed revoked. FURNACE: FAU GRAVITY 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. 0 License Number Lic. Class D V ®C Contractor Date 0 t V • ❑ I am exempt under Sec: - 1 #';2 �,¢,� y Plan check fee B.&P.C. for.this r son' I ,o,o 2 115 0 z -PERMIT ISSUING-FEE $ D Signature TOTAL FEE CLAEd-BUILDER DECLARATION PLAN CHECK APPLICANT U I hereby affirm that f am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and NAME Professions Code'): ❑ I, as owner of the.property, or my employees with' ADDRESS ( ^ wages as their•.sole compensation,-will do the.work and the structure is not intended or offered for sale(Section CITY TEL. NO. 7044, Business and Professions Code). ' OWNER ❑ I, as owner of the property, am exclusively contracting with. licensed contractors to construct'the project (Sec- MAIL tion 7044; Business and Professions Code). ADDRESS . . CONSTRUCTION LENDING AGENCY CITY TEL. NO. I hereby affirm that there is a construction lending agency for D the performance of the work.for which this permit is,issued CONTRACTOR (Sec. 3097, Civ. C.). ADDRESS L Lender's.Nome CITY TEL. NO. Lender's Address STATE LIC. I certify that I have read this application and state that the LICE CLASS ' above information is correct. I agree to comply with all County ordinances and State laws relating to building construction, and reby authorize representatI s of this ounty to enter po bove-m ti ed operty or in tjo purposes. SEE REVERSE FOR EXPLANATORY.LANGUAGE i at re of'Applicant or Agent Dat - - ZZWORKERS'COMPENSATION DECLARATION G �11�If L� CG�1 11 11 V l!—OO PERM U - that I have a certificate of consent to self t msrure, or a certificate of Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING or a certified CE-81 copy thereof (Sec. 3800, Lab. C.) CC E 818(REV. 10/81) Policy No. Company CeHifiecJ copy is hereby furnished., COUNTY OF LOS ANGELES BUILDING AND SAFETY a .Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING61 r� tion department. (PRINT OR TYPE ONLY) ADDRESS Date Applicant LOCALITY NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST COMPENSATION INSURANCE CROSS ST. (This section need not be completed if the•work involved by ABSORPTION UNIT, BTU DISTRICT NO. PROCESSED 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 BOILER, BTU so as to become subject to the Wor rs' omp sation Laws. j/1' nPPRovats DATE N 6CT0 'S SIGN TORE Date pplicanT COMPRESSOR, BTU OD r(,f ROUGH' r J ' NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL ��s Exemption, you should become subject to the Workers' tr 41 Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER N with comply with such provisions or this permit shall be deemed revoked. FURNACE: FAU Y GRAVITY -LICENSED CONTRACTORS DECLARATION FLOOR BTU le 1,42 I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT'(commencing with Section.7000) of Division 3 of WALL the Business and Professions Code,and my license is in full force and effect. 0 'License Number Lic. Class V Contractor Date ' / p o 7_S 56 'e O a1 am exempt under Sec. 9 2 9.3 A W Plan check fee 'd H 8.&P.C. for this reason PERMIT ISSUING FEE $ # ®'o o'•o 8 z Date: TOTAL FEE Signature e o a$,0 0 OWNER-BUILDER DECLARATION., PLAN CHECK APPLICANT I hereby affirm that I am exempt from the Contractor's License 0 0 0 4 8.0 0 Law for the following reason (Section.7031.5, Business and NAME V i2 - C7 t.5 OPS/ D Professions Code): / 0 4,0 2;=8 8 ❑ .I, as owner of the property, or my employees with ADDRESS b 6'Z �?� - wages as their sole compensation, will do the work and the structure is not intended or offered for sale(Section CITY / TEL. Na ' 7044, Business and Professions Code). v ❑ L I, as owner of the property; am exclusively contracting OWNER 40le-/ With licensed contractors to construct the project (Sec- MAIL .tion 7044, Business and Professions Code). '• ADDRESS CONSTRUCTION LENDING AGENCY " 1 'TEL. NO. I hereby affirm that there is a construction lending agency.for D the performance of the work for which this permit is'issued CONTRACTOR �Z1 (Sec. 3097, Civ. C.). .ADDRESS Lender's Name CITY TEL. NO. Lender's Address STATE LIC. I certify that I have read this application and state that the LICENSE NO. CLASS above information is correct. I agree to comply with all County ordinances and State laws relating to building construction, a hereby aut rize representatives of this County to enter p n the abo - en7ed property for(insspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE �I Signature of Date Applicant or Agent. -