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HomeMy Public PortalAbout9139 LAS TUNAS DR_Mechanical__ WORKERS' COMPENSATION DECLARATION APPLICATION FOR PERMIT I hereby.affirm that I have a certificate of consent to self insure,-or a certificate of Workers' Cpmpensation Insurance, HEATING - VENTILATING AIR CONDITIONING ora ceraified copy thereof (Sec. 3800, Lab. C. 76A364C 1. 20-0046 DPW 9/88 Policy No.—Company' COUNTY OF LOS ANGELES BUILDING AND SAFETY ❑ Certified copy is hereby furnished.. El Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING (� .-. tion department. ADDRESS J (PRINT OR TYPE ONLY) Date - Applicant LOCALITY NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST COMPENSATION INSURANCECROSS ST. (This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO. PRO SED BY the permit is for one hundred dollars ($100) or less.) ot I certify that in the performance of the work for which thisAIR HANDLING UNIT, CFMpermits issued; 1 shall not employ any person in•any manner so as to become subject to the Workeis'Co sation Laws. BOILER, BTU APPROVALS DATE INSPECTOR'S SIGNATURE Date. Applicant COMPRESSOR, BTU N z k ROUGH 4F 1 NOTICE TO APPLI ANT: If, after m ing this Certificate of VENTILATION SYSTEM FINAL Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- 11/ L D TI N with comply with such provisions or this permit shall be deem- ed revoked. FURNACE: FAU GRAVITY LICENSED CONTRACTORS DECLARATION FLOOR BTU I hereby affirm that I am licensed under provisions of Chapter 9HEATER: 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. .Oniou License Number b���L� Lic. Class N1111.�t �LAS o - .�- o Contractor � ate OC E] I am exempt under,Sec. 0 Plan check fee B.&P.C. for this reason. W Date: PERMIT ISSUING FEE $ Z 11 Signature TOTAL FEE BUILDER DECLARATION OW PLAN CHECK APPLICANT I hereby affirm that I am exempt from the Contractor's License , Law for the following reason (Section 7031.5,Business and NAME t Professions-Code): ADDRESS ❑ I, as owner of the property, or 'my employees with A-1—7, s wages as their sole compensation, will do the work and NO. the structure is not intended or offered for sale(Section CITY TEL. ' 317 7044, Business and Professions Code). OWNER ❑ I, as owner of the property, am exclusively contracting 1 ITEMS with licensed contractors to construct the project (Sec- p4.F I tion 7044, Business and Professions Code). ADDRESS3� OL�kk�/ VP TOIAL .- CONSTRUCTION LENDING AGENCY CITY TEL. NO�/ � `L �;�+} 70.50 I hereby affirm that there is a•construction lending agency for :7 ��+ _ -- the performance of the work for which this permit is issued CONTRACTOR l.y�� , GNfihi>iE . °� ; (Sec. 3097, Civ. 1C..). Lender's NamelrQri[^�r/-r�'���—�/r`� r� (�60. 1 ADDRESS ,(_J O i{�/ / �J N Uy/(� f u J, CITY&r7,.r(1 TEL. NO '0000-0001 if t! s:/v Lender's Address r i� `^v � -, e M;t I certifythat I have read this application and state that the STATE LIC. 603.5 1 AMI1°::7 pP LICENSE NO. �2-� CLASS4cla C above 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 thepJamc e;l�ned property for inspection purposes: (/$ SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent Date ©s WORKER'S COMPENSATION DECLARATION " 20-0046 DPW 9/89 APPLICATION FOR PERMIT `I .GREE 76A364C I hereby.affirrrr that I have a certificate of consent to self insure, ora certificNe 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. -� ❑ 'Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN ADDRE S 13 � I (.�/l� p -- department. (PRINT OR TYPE ONLY) Date Applicant LOCALITY „ NO. TYPE OF APPLIANCE OR EQUIPMENT. FEE I (' CERTIFICATE OF EXEMPTION FROM WORKERS' - NEAREST 1 ^, CROSS COMPENSATION INSURANCE UO 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($100)or less.) AIR HANDLING UNIT;CFM DISTRICT NO, PROCESSED BY I certify that in the performance of the work for,which this permit is issued, I shall not employ any person.in any manner so as to BOILER,BTU become subject to the Workers'Compenstion Laws. f�Il��a' p Y�j COMPRESSOR,BTU Date �O 2Applicant L � VENTILATION SYSTEM APPROVALS DATE INSPECTOR'S SIGNATURE NOTICE TO APPLICANT: If, afteh;making this Certificate of ROUG 5 _ Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER r provisions of the Labor Code, you must forthwith comply with such FINAL �J provisions.or this permit shall be deemed revoked. FURNACE: FAU GRAVITY LICENSED CONTRACTORS DECLARATION FLOOR _BT u VALIDATION I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT (commencing with Section 7000)of Division 3 of the Business and WALL Professions Code,and my license is in full force and effect:I "r Ill �IFZ l� f0L4T( &-Tj 3 O License Number �O �D Lic.Class A(, 'r'(Ont PPV fSKESTMO A. Contractor to_ ` 2 ❑ I am exempt under Sec. Plan Check fee B.&P.C.for this reason PERMIT ISSUING FEE$ ' O0 J. Date: TOTAL FEE 3' a Signat r9 A (A WNER-BUILDER D ATION - PLAN CHECK APPLICANT - •• Z :., d hereby affirm t at I am exempt from the Contractor License Law NAME I"' t for the following reason (Section 7031.5, Business a d Professions Code):. ADDRESS _.... ❑ I, as owner of the.property, or.my employees with wages r't: s as their sole compensation, will do the work and the CITY TEL.NO. structure is not intended'or offered for sale (Section 7044, ML- Ty Business and Professions Code). ,OWNER ANcA �A( ❑ Jy j 1, as owner of the.property, am exclusively contracting MAIL /� with licensed'contractors to construct the project (Sec- ADDRESS i3 7.U�/`i �(�- ,;,_�a.;ty;•r;t-. '€;_; tion 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY CITY '���W+ Lia C (T TEL.NO.0(S— Z� I hereby affirm that there is a construction lending agency for _ _. the performance of the work for which this permit Is issued CONTRACTOR �`�! W b {�J (�r�S (L,�/bj.� i%' 'w. (Sec.3097,Civ.C.).' �t,py L�� 1�p� - ADDRESS 1�`47D I O14 IJ x'74, 9b'* "b �f Y.'.. AN Lender's Name �,, �� CITY W r�•7,4�p6 _ TEL.NO.141-1 2661 24 Lender's Address I certify that I have read this application and state that the above LICENSE NO. 0 d 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 u on the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE JSIGNATURE OF APPLICANT OR AGENT # -WORKERS'COMPENSATION DECLARATION CE 8 48C(2 BO) � p FIp �C /n, T�O ft p FOR fob E R I1L1 T I ,ereb)-,a%ifm that I have a' certificate of consent to self G J L� /rel CI tf1S If— L�If1C�V� insi:, or e..certivicate of Woikers'Compensation Insurance,or HEATING-VENTILATING-AIR CONDITIONING •a certifi,d copy thereof(Sec.3800,Lab.C.) Policy No.-' Company ❑ Cectified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY ❑ Certified copy is filed with the county building inspection BUILDING ^ department. FOR(PRINT TTO FILL IN Date Applicant (PRINT OR TYPE ONLY) ADDRESS_ CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY COMPENSATION INSURANCE NEAREST CROSS ST. (This section need not be completed if the work involved ABSORPTION UNIT, BTU a by the permit is for one hundred dollars ($100) or IeSS•) DISTRICT NO O� PROCESSED O 1 certify that in the performance of the work for which this AIR'*'' ANDLING UNIT,CFM �. permit is issued, I shall not employ any person in any manner �Datc asto ec me subject to the v kers' f o rpensati�n Laws. BOILER, BTU �� 0 APPECTOR'S SIGNATURE+ � Applicant COMPRESSOR,BTU ROUGH d 1OTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM Z Exemption, you should become subject to the Workers' FINAL L� P # Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER (/ p, I[] J 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 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. ( /Tv License Num' .:� _ •,ic.Class + �-V Contractor Date 411" ❑ 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- d iness and Professions Code). PERMIT ISSUING FEE $ �� Lie.or Reg.No. Date TOTAL FEE S� HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT I hereby affirm that I am exempt from- the Contractor's NAME o License Law for the following reason (Section 7031.5, Busi- g .. Hess and Professions Code): ADDRESS �+4T A AC •7 _ ❑ 1, as owner of the property, will do the work and the structure is not intended or offered for sale (Section CITY TEL.NO. �7M7 .Cf7•C 7044, Business and Professions Code). 1 1 ITG1h7 .N1 ❑ _. I, as owner of the property, am exclusively contracting OWNER /� with licensed contractors to construct the project MAIL TOTAL 50.50 (Section 7044, Business and Professions Code). ADDRESS MICK50 CONSTRUCTION LENDING AGENCY CITY TEL:NO. f ��.uu S�• I hereby affirm that there is a construction lending agency CHANE •00 for the performance of the work for which this permit is CONTRACTOR (IR£E A)COO-OD EA1;r&�LI�if�S`. issued(Sec. 3097,Civ.C.). Lender's Name ADDRESS Lender's Address �1 8/�10/8 CITYc(J10(J j TEL.NO.�oC(_' 60� 5031 1 AM10.Ob I certify that I have read this application and state that the STATE ��I—n� /J� LIC. n ^7 • above information is correct.I agree to comply with all County LICENSE NO. F �r/ CLASS ordinances and State laws regulating Heating, Ventilating and Air Conditioning, and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE Count ') enter upon .te above-mentioned property for us cti ,purposes d�?19 5 gnature of Permt tee Date