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HomeMy Public PortalAbout9923 LIVE OAK AVE_Mechanical__ WORKERS' COMPENSATION DECLARATION n PPUCA�� N FOR PERNT I�eby`affirm that I have a certificate of consent to self , - /� u� ' Insure, or a certificate of Workers' Cwrpensation Insuraiice, I HEATING - VENTILATING - AIR CONDITIONING or a c i copy there o (Sec 3 ab C 76A364C 20-0046 DPW 9/88 PoIIc��V�/_-72�� � `7`omp COUNTY OF LOS ANGELES BUILDING ARID SAFETY Certified copy is hereby furnish d i Certified copy is filed with e ou but ng Inspec- BUILDING tio41PApplican FOR APPLICANT TO FILL IN ADDRESS (PRINT OR TYPE'ONLY)Date d LOCALITY NO TYPE OF APPLIANCE OR-EQUIPMENT -FEE CERTIFICATE OFIEXEM FROM W ERS' - NEAREST COMPENSATI INSURAN CROSS ST (This section need not be completed if.the work involved by ABSORPTION UNIT, BTU I 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 ' n O permit is Issued, I shall not employ any person in any manner (� e so as 10 become subject to the Workers' Compensation Laws - BOILER, BTU APPROVALS DATE INSPECTOR'S SIGNATURE Date Applicant COMPRESSOR, BTU -D© O i ROUGH NOTICE TO APPLICANT If, after making this Certificate of VENTILATION SYSTEM FINAL Exemption, you should become subject 'to the Workers' Compensation provisions of the Labor Code, you must forth- EVAP,ORATIVE,COOLER' s VA IDATION with comply with such provisions or this permit shall be deem- ed revoked I I ' ' / FURNACE FAU GR ITY LICENSED CONTRACTORS DECLARATION [, FLOOR BTS 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 forSr and effect (�[ License N Lic Class D: 0 O p' u Contra Date OC E] exempt un Sec O Plan check fee u B&P C for-this reason H PERMIT ISSUING FEE $� Date TOTAL FEE AAW Signature OWNER-BUILDER DECLARATION 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 D Professions Code) l ❑ I, as owner of the property, or my employees with ADDRESS-- wages as their sole compensation,will do the work and ii•�•t °a the structure is not intended or offered for sale(Section CITY t TEL NO 7044, Business and Professions Code) `3317 cc°I l'l El I, as owner of the property, am exclusively contracting OWNER with licensed contractors to construct the project (Sec- MAIL �Q-�,� B� ITEMS tion 7044, Business and Professions Code ADDRESS 3 i'li[ c_ 55 TO CIO CONSTRUCTION LENDING AGENCY CITY. TEL No ¢ 7j V rr I hereby affirm that there is a construction lending agency for �+ 6 tE'v:r• _i_t,ljll the performance of the work for which this permit is issued. CONTRACTOR D CHANCE (Sec 3097, Civ C ) ADDRESS Lender's Name CITY TELNo J! i '1,301313-0 0 j 10/y6P,11 Lender's Address ��-If- ! 35333 hr ° I cern that I have read this application and state that the STATE LIC` _ � t E =°q pp LICENSE NO CLA above information is correct I agree to comply with all County ordinances and State jaws relating to building construction, ereby aut ze representatives of this County to enter ZWf entioned property for inspe tion pur oses SEE REVERSE FOR EXPLANATORY LANGUAGE d" 1 plica Agent Date l ... . Os WORKERS' COMPENSATION DECLARATION APPHICAMN FOR PERMT I hereby affirm that,I have a certificate of consent to self injure, or a rerfificate of Workers' Com ensation Insurance, IIE�,YIA1G . VENTILATING - AIR CONDITIONING or a cert fA co y thereof e 3� L C ) 76A364C � 20 0046 DPW 9/88 Policy oefmpan ❑ Certfied.copy is hereby furnishe' COUNTY OF LOS ANGELES BUILDING AND SAFETY- Certified copy is filed with the ounty building mspec- FOR APPLICANT TO FILL IN BUILDING �s Tion a ent ADDRESS (PRINT OR TYPE ONLY)_ f� Date S Applicant LOCALITY NO TYPE OF APPLIANCE OR EQUIPMENT- FEE CERTIFICATE OF EXEMPTI FROM WO S' 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.) AIR HANDLING UNIT, CFM n� I•certify that In the performance of the work for which this L/ peFrTiit is issued, I shall not employ any person'in any manner so,as.to become subject to the Workers'COmpen sation,LawS BOILER, BTU APPROVALS DATE NSPECTOR'S SIGNATURE Date Applicant COMPRESSOR, BTU ROUGH NOTICE TO APPLICANT If, after making 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 VALIDATION with comply with such provisions or this permit shall be deem- ed (evoked 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 fullort fnd effect f d. License Nu r� / Lic Class D ,O Contracto ate .S � ❑ : 1• exempt and ec O Plan check fee u B 8P C for this reason W x y _ Dare PERMIT ISSUING FEES _J — W Signature TOTAL FEE ' / OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT I hereby affirm that I am exempt from the Contractor's License D Law for the following reason (Section 7031 5, Business-and NAME Professions Code) I i ❑ I, as owner of the property, or my employees with ADDRESS wages as their sole compensation, will do the work andCITY' TEL NO T` °H the structure is not intended or offered for sale(Section 704 Business and Professions Code) OWNER `-I ' r •i=�I ❑ I, as owner of the property, am exclusively contracting -MAIL I EE d' - 00 with licensed contractors to construct the project (Sec- - !t '' p tion 7044, Business and Professions Code) � ADDRESS � )-1'�f9L 4� CONSTRUCTION LENDING AGENCY • CITY TEL NO /� CHECK I hereby affirm that there is a construction lending agency for _ 17.&t_1 the performance of the work for which this permit is issued CONTRACTOR t•i-1AiNGE (t[I (Sec 3097, Civ C ) ADDRESS /,3S-,--,b Lender's Name CITY NO Lender's Address �= I certifythat I have read this application and state that the STATE LIC w ''''�f' f1. �3�a PP LICENSE NO 1 'CLASS above information is correct I agree to comply with all County ordinances and State laws relating to building construction, ' and by authoriz representatives of this County to enter upon th o e- coned pro erty for ms ec onVposes - 00 SEE REVERSE FOR EXPLANATORY LANGUAGE Sigat e'of Applicant gent Date PS