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HomeMy Public PortalAbout10101 LANDSEER ST_Mechanical__ WORKER'S COMPENSATION DECLARATION 20-0046 DPW 9/89 AP LIGATION FOR PERMIT' LI E GREEN ' I'hereby affirm that I have a certificate of 76A364C•consent.to self insure, - r,: or a�.ertificate of Worker's Compensation Insurance, or a•certified Hij ITINGJNENTILATING-AIR-CONDITIONING copy thereof(S c 3800 Lab C) Policy No Company COUNTY OF LOS ANGELES DEPT OF'PUBLIC WORKS 'BUILDING'AND SAFETY DIV. ❑ - Certified copy is-hereby furnished. ; C rtiil copy Is filed with the con buildingInspection FOR APPLICANT TO FILL IN BUILDING d pa Ment (PRINT OR TYPE ONLY)• ADDRESS © l - Date _Applicant LOCALITY 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 F permit Is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO'. PROCESSED BY (,certify that'in the performancq,of the work for which this permit is Issued, I shall not employ any person In any manner so as to BOILER,BTU become subject to the Workers'Compensation Laws �� - - COMPRESSOR,BTU gppgOVALS .. DATE•' , INSPECTOR'S SIGNATURE - Date' Applicant - VENTILATION SYSTEM NOTICE TO APPLICANT If, after making this Certificate of ROUGH',, ,Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER provisions of the'L'abor Code; you must forthwith comply with such FINAL provisions or this permit shall be deemed revoked. ` FURNACE. FAU ITY LICENSED CONTRACTORS DECLARATION Q FLOOR BTU o VALIDATION I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT (commencing with.Section 7000) of Division 3 of the Business and HEATER WALL- Professions ALL Professions Code, and my license is in full force and of License Number Lia Cor 4 CoractorMAODate' ✓� , ' _ 0 nt Pfan check fee V ❑• I am exempt under Sec. �. PERMIT ISSUING FEE$ �� L3 I ns B.&P C.for'this reason # -I t` �- T't -- r V Date, j TOTAL FEE til 1.ITEMS d Signature' - OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT TOTAL(TAL .77 ® 70 z herel y'affirm that I:am exempt-from the Contractor's License Law NAME -`� for.the-following reason (Section 7031.5, Business and Professions , 4.�E4:.}� {f.7�I J 3 .f Code): ADDRESS 1 r_HANGE n It I, as owner of the property, or my-employees with wages as their.sole compensation, will do•the work and the CITY TEL`NO: ; structure Is not intended or offered for sale (Section 7044, C Business and Professions Code). OWNER' i i tr El 1, as owner of the property, am exclusively contracting I MAIL 1�1= 1 Ar`jt19227 With licensed-contractors to construct the project (Sec- ADDRESS tion-7044, Business and Professioris Code)., CITY TEL.NO CONSTRUCTION LENDING AGENCY 1-hereby affirm that there'is a construction lending agency for CONTRACTOR , th'e performance - - ' (Sec.3097,Civ.C.). of the work for which this permit Is Issued ADDRESS x Lender's Name 1 CITY :TEL NO._ 'Lender's Address STATE LIC I certify that I have read this application and state that the above LICENSE NO. CLASS Information is correct. I agree to comply with all County ordinances and State laws re g to building construction;and hereby authorize representativ o this County �to�enter upon the above-mentioned property/ r ec i n purpos✓`' SEE REVERSE FOR EXPLANATORY LANGUAGE _ 4 SIG OF AP ANT OR AGENT DATE - 76 A364 - CE 818 -1/75 APPLICATION FOR PERMIT' HEATING - .VENTILATING - AIR CONDITIONING COUNTY OF LOS ANGELES BUILDING (� c—�'-✓�. DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION LOCALITY NEAREST CROSS ST. 7�/ FOR APPLICANT TO FILL IN OWNER ` (PRINT'OR TYPE ONLY) - MAIL NO. TYPE&SIZE OF EQUIPMENT FEE ADDRESS sTv-J • ' , SEE BACK OF APPLICATION (J� - CITY TEL. NO. FORCE AIR FURNACE, BTU CONTRACTOR COMPRESSOR, BTU ADDRESS L.) v6' 0y}J VENTILATION FAN CITY j� TEL. NO. '14(_X J'' LIST ALL OTHERS BELOW STATE ^ LIC. n LICENSE NO. 0-� �'b CLASS C_X 71 `/R,A 1• ,�.y� DISTRICT NO. GROUP ZONE ROC SED BY INSPECTION RECORD a O' U W N .Plan check fee. See reverse. z 11F1011T ISSI;I\G FF;.I': c - 0 PLAN CHECK APPLICANT ' NAME ADDRESS CITY' TEL.NO. I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION ' AND STATE THAT THE"ABOVE IS CORRECT AND AGREE TO COMPLY - WITH ALL ORDINANCES AND LAWS REGULATING HEATING', VENTI- APPROVALS DATE INSPECTOR'S SIGNATURE LATING, AIR CONDITIONING ROUGH I HEREBY CERTIFY TH T2AMOT ACTING INVIOLATIONOF CHAPTER 9, DIVISI 3 INESS D PROFESSION L FINALCODE OF THE STATE C LI O - •SIGNATURE PERMIT-VALIDATION CK. M.O. CASH OF PERMITTEE PLAN CHECK VALIDATION CK, M.O. CASH 3 8 0 npR 1641 0 5.7 5 ���