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Home My Public Portal About9223 LEMON AVE_Mechanical__ 3 WORKER'S COMPENSATION DECLARATION 20-0046 DPW 9/89 76A364C APP`LICATIOW FOW�OERWT ` s � I hereby aifir`rrlttiat'I have a certificate of consent to self insure, Ll E ',GREEN, or aicertrt Cate of;W�roKer's CrWpensation Insurance, or a Certified " HEATING -VENTILATING -.AIR'CONDITIONING; 4'' copy'thereof(Sec 3 00 Lab C) " .f e • Policy,'No ' - Company ~ 4 ','COUNTY.OF LOS'ANGELES- r�'> DEPT OF PUBLIC,"WORKS','& -••}+ BUILDING AND SAFETY DIV. "❑ Certified copy is hereby furnishedA + ❑ „Certdied copy is filed with the county budding inspections r AA FOR APPLICANT TO FILL IN ADDRESS ,department •� ++`, '` �, ' i. (PRINT ORTYPE�ONLY), - - , $ Date Applicant `V _ LOCALI'T.Y' z`. y �:, NO TYPE OF APPLIANCE OR EQUIPMENT FEE -CERTIFICATE'.OF^EXEMPTION FROM WORKERS' NEAREST CROSS STr x COMPENSATION INSURANCE '}j ABSORPTION UNIT,BTU ASSESSOR �' (This section need not be completed',if-the work involved by the - MAP BOOK ��2' PAGE/ P,ARCE�/` Permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM f1• 7 DISTRICT NO - PROCESSED BY ,•I certify that in',the performance of the work for which_this_permit . ; + is,lssued, I shall not.employ any person In any manner sol as to BOILER;BTU J become su6)ect_to the Workers'.Compensation Laws, �/O ,COMPRESSOR;__BTU' . - ,s.•�- - - •__ r- - - < APPROVALS '- DATE NSPECTOR'SSIGNATURE Date Applicant VENTILATION SYSTEM f t•J aNOTICE,,TO^APPLICANT If, afterfmaking,thisaCerhficate-of:� ,ROUGH ., t 'Exemption,you°should'become sdblect'to_the•Workers' compensation EVAPORATIVE COOLER FINAL- provisions of'the Labor Code;.you must forthwith comply`wrth such , - provisions or this permit shall b'e deemed revokedFURNACE -FAU GRAVITY` LICENSED-CONTRACTORS DECLARATION a •. ''FLOOR BTU VALIDAT, N , I hereby affirm that I-am,lroensed under'provisions of Chapter 9 SUSPENDED' UNIT (Commenciri9 with Section',7006);of Division 3 of'the Business and HEATER ;'WALL Professions Code,andlmy license is'in'•full force and,effect ,w r _=,_a;r .c� H - .T,o'�n - -- .-otic :a��'_` _ ' ter, _ - ,.. -, --�,• � v_ .i- �- :<; • ' .k, License Number ��'' Lic Class' = Contractor Date 0 ❑., I am exempt under Sec Plan check fee �. B&P C for this reason 7— PERMIT ISSUING FEE$ ��j ir DateTO,TAL''•,FEE16 :. t ti •,+ r _Ery W Signature s &r 4��s. " n- ^• a PLAN CHECK APPLICANT .� OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License'Law NSE "for the following:reason'(Section 7031 5, Business and'Professions ° ' -ti' _ ;,S,f '`j� ;ti_ Code).. ADDRESS 1; , fir _I ❑{ I, as owner of the propertyoi my employees with wages as their sole compensation;- will do the work.and the ,' CITY .TELT NO 4 structure'is novintended or offered f_br sale'(Sectron 7044 Business and Professions Code) �, ;� OWNE I, as owner of the property, am_exclusrve'ly contracting fgAIL�. ' ��T� with.licensed"contractors toyconstruct the pro/ect (Sec= ADDRESS" tion 7044, Business and Profes'sions•Code) • •'` CONSTRUCTION LENDING AGENCY C EL NO' ' d't�,), I hereby affirrri`that°thereflss a''construction lending agency,for the,perform ariceaof the work for,_'which this permit is.issued CONTRACTOA (Sec'.3097, Civ C) 4, ADDRESS " •;Lender's6me' t ,' v• k K,� .,�,, Y-.r r CITY TEL NO •Lerider's Address d r STATE c LIC n" :'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 ordmances :el: rti and State laws relating to budding construction,and hereby authorize i '. •;y ;�., represe es of this County to enter upon'the above-mentioned R 'pro y' Insp tion pu SEE REVERSE FOR EXPLANATORY'LANGUAGE .r SIGNATURE OF APPLICANT R AGENT - DATE,' ,- - r - •, O r'�r �` WORKER'S COMPENSATION DECLARATION `t �' 520-0046'DPW 9/89 - w ' � � •"" � - - • `I hereby affirm tftaf I have•a certificate of consent to'elf insure,' ., ''6A3 C g'' APPLICATION FOR PERMIT LIME'° 'GREE'N or a ceitif(cate'$of'Worker's Cqm ansa{ion Insurance,'or Ys.- = » p a certified :HEATING-•VENTIL"ATING-AIR CONDITIONING copy ther6 ((SSec�3�0�0-LLab C) f. _ ,•' '' - ' •' 't t ;'`%t •. �', i" ., pp�/� Policy No "�G6mpany"' UNTY OF'LOS'ANGELESDEPT•OF PUBLIC WORKS BUILDING AND SAFETY DIV. r , Certfied'copy is�hereby,furnished Certihed`copy,is fled with the c nty'liwlding,inspection ; -FOR'AP,PLICANT;TO FILL IN BUILDING 'COADDRESS •-` department J` •R•'• r _ ., , 't(PRINT OR TYPE ONLY) � _ - >a •• r + t - LOCALITY; Date¢ `� �4pplicant`` 'NO TYPE F APPLIANCE ORE ' O QUIPMENT + FEE CERTIFICATE,OF EXEMPTION FROM-WORKERS'-. ` z• r CROSS ST { °NEARESTq� - COMPENSATION,INSURANCE. N_ - , ABSORPTION UNIT,,BTU ASSESSOR p (This section need,not be completed,If the work rrivolved,by the', k - MAP BOOK � D .� PAGE ��,�, ,PARCEL�c/ ,permit is for one huniJre'd dollars;($100)'or less)•-, �'_ ,L • "kr AIR HANDLING UNIT,CFM` v ,, PROCESSED BY J' 1 tL' - J • � ' DISTRICT NO I certify that in the performance o,,the work for which'tlthls'permit' ' is•issued, I shall notem to an person in an manner.so as to , P Y Y P Y BOILER,BTU 4 .become subject,to the-Workers'Com' nsatio�Laws ¢ < `1' " COMPRESSOR;BTU >Date�� ' e e Applicant ,`yvY JI• ' - 1. - t APPROVALS _ ' ",PATE ., r``NSPECTOR S SIGNATURE,11, VENTILATION SYSTEM' _ _ - NOTICE'TO4APPL'ICANT-If*after`maki g�thiS7C`ertlflcate of,— 14 `' f '" "' �` -'" t ROUGH y Exemption,you should'become•sublect to•the Workers'Compensation " '°' Y T EVAPORATIVE COOLER' ''provisions of.the Labor Code, you rriust'forthwrth comply with such FINAL _ provisions orathis:permit.shall be deemed revoked FURNACE FAU GRAVITY ' LICENSED CONTRACTORS DECLARATION_ fir, FLOOR BTU ,� �: VALIDATION, �I hereby affirm that.1'am,-licensed under provisions of'6hapter'9 SUSPENDED' UNIT ) HEATERti. (commencing wrth'Secfion 7000) of Division 3 of the Business and WALL' Profess16ns•C6d6,and my-license is in=full,force and effect n. - , Lldense Number' Lic Class = ! • p-''»� r,�` --tee-' ,,S- .. _ ' L)••• , v Contracto ate r Y' �: I am ex m I Plan Check fee e pt,under Sec B&P C'for this reason � ti - PERMIT ISSUING FEE'$` �r _ D h ,TOTALi FEE •-r''r ; #'t f _ - W Signature `_` t' / '' ' r fA OWNER-BUILDER DECLARATION PLAWCHECK APPLICANT Z 1,herebyaffirm,that I'am exempt from-the Contractor's License Lew for the,follbwing,re ( NAME r ason Sectiori 7031.5, Business.and Professions. �e): - -}, - y +'. ADDRESS - { n I, as-owner of,,the property;,or my employee's with wages Y' as their sole compensation, 'will do the work and'the CITY ` 4• TEL NO° t r i:t•^ti'1 }'f s, t. structure is not intended onoffered for sale,(Sectiom7044, Business and Professions Code) " WNER F as owner,of th r £ j e p operty, am exclusively contracting MAIL �.tiLQ��--� 'WOV with licensed contractors to-construct,the,profect>,(Sec- rt ADDRESS , r ";' .(=e EI Y• yt+`j ' `='yU y_ tion 7044,,Business•and Professions Code) • 'f• . CONSTRUCTION LENDING AGENCY Cl tTEL yN0 a tl �} hereby'affirm that there is a construction'lending agency for the'Performance of the,work`for which this,perm it is issued ONTRACTOR , r �•- (Sec 30,97;Civ 'C) �^ �j - ^;w ., ."•'t''�9 'i,.e., - • ,I �, ADDRESS •7' ✓ - �� ,,,�� '_{. ,. Lender�s,IJame p - mss: ' CITY TEL NO.n��O Lender's Address i,_+J § ATE LIC a :+ I certify''that'l_have_read'Ais applii:ation and state that the above, LICENSE,NO • ; 7- CLASS, ? information is correct I agree to comply with all County'rordmances-; and State laws relating to buildihg construction,and tiereb 'aut6eize� Y,+• ,' repre atives of is County to enter upon the above-mentioned'" e for n • coon p r 'SEE REVERSE�FOR'EXPL'ANATORY•,LANGUAGE pre UR F APPLICANT AGENT,.- - D�� a• f- �t i - Y' - YI-,a� �, '..�--