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Home My Public Portal About6236 LOMA AVE_Mechanical__ A1VORv,ERS'COMPENSATION DECLARATION APPM (CATMN FOR PERMIr I here�afi`irm that I have a certificate of'consent to self Insure, or a.certificc!4_- at Workers' Compensation Insurance, HE - VENTILATING - AIR'CONDITIONING or a certified,copy thereof KK(Sec 3800, Lab C ) 76A364C Policy No720786— Cern, pony State Fund CE-818(REV 10/81) ; - 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 department (PRINT OR TYPE ONLY) 'ADDRESS 6236 Loma Avenue ,Date 9-16-86 Applicant LOCALITY Temple City NO TYPE OF APPLIANCE OR EQUIPMENT FEE CERT_IFICATE,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 P CESSED BY the permit is for one hundred dollars ($100)or)ess.) AIR HANDLING UNIT, CFM t ; I 'certify that in the performance of the work for which this peiinit is Issued, I shall not employ any persowin any manner BOILERBTU so as to ,become subject to the Workers'Compensation Laws - APPROVALS DATE INSPECTOR'S SIGNATURE • Date Applicant COMPRESSOR, BTU 0 ROUGH /0/3 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 _ VAI AT ON with comply with such provisions or this'permit'shall be deemed revoked FURNACE FAU GRAVITY LICENSED CONTRACTORS DECLARATION i FLOOR BTU U I hereby affirm that I am`licensed under provisions of Chapter 9, HEATER SUSPENDED ' ` UNIT (commencing with,Sectton 7000) of Division 3 of the Business WALL`— and ALLand Professions Code,and my license Is in full force and effect' License Number475228 Lic Class CO2O 0 D v D 99 Contractor Env Eng. Ddte 9-16-86 i 0 I am exempt,under Sec Plan check fee B &P'C for this reasontA PERMIT ISSUING FEE Q `U z Date TOTAL FEE I Signature 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, 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 ;_9 5 4'6 3'A •7044, Business and Professions Code) # e e o o e 8 ❑ I, as owner of the property, am exclusively contracting OWNER Becker with licensed contractors to construct the project (Sec- MAIL ADDRESS same J .e 041.00 tion 7044, Business and Professions Code) CONSTRUCTION LENDING AGENCY CITY` ' TEL NO' e e o"(� O O CJ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued CONTRACTOR Environmental Eng. 0 9,,1 ,8-, 86 (Sec 3097, Civ C ) _ ADDRESS - OZ N. -Poplar Lender's Name Lender's Address CITY Orange TEL N6639-8281STATELIC _ I certify that I have read this application and state that the LICENSE NO 4 15228 C ASS ri-2 _ 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 the above-mentioned,property for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE, -- Q45212 Lx 9 I 1, -2 Signature of Applicant or Age t Date - _} WORKER'S COMPENSATION DECLARATION" 2"046 DPW 9/89 APPUCATT O IN FOR'PERMIT IT 76A3 =1 hereby affirm that I have,a certificate of consent to self Insure, 76A364C LIAAE. GKEEN or a certificate of Worker's Compensation Insurance, or a certifiedHEATING -VENTILATING-AIR CONDITIONING • copy thereof(Sec 3800 Lab C) Policy N P 51'I-0-" CDIYflmafiy rU�. CO/APeN �dN COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV. ❑ Certified copy is hereby furnished —� fL}�SJ Certified' y 9p ADDRESS copy is flied with the count buildin Ins action FOR APPLICANT TO FILL IN BUILDING r department (PRINT OR TYPE ONLY) _ Date AppI I c a n t,�. LOCALITY , NO TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST CROSS ST COMPENSATION INSURANCE ABSORPTION UNIT,BTU •(This'section need not be completed If the work Involved by the ASSESSOR permit is for one hundred dollars(x100)or less.) s MAP BOOK- PAGE PARCEL AIR HANDLING UNIT,CFM 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 so as to BOILER BTU r become sub/pct to the Workers'Compensation Laws COMPRESSOR,BTU "'7 ��•�/� _ � � APPROVALS DATE `INSPECTOR'S SIGNATURE Dat VENTILATION SYSTEM NOTKUC TO APPLICANT If, after making this Certificate of ROUGH Exemption,you should'become subject to'the Workers'Compensation EVAPORATIVE COOLER provisions of the Labor Code, you must forthwith comply with such FINAL provisions or thls�permlt•shall be deemed revoked FURNACE FAU AVITY // -LICENSED CONTRACTORS DECLARATION FLOOR BTU (O �� V LI TION I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED—UNIT— (commencing USPENDED UNIT(commencing with Section 7000) of Division 3 of the Business and HEATER WALL O Professions Code,and'my license Is In full force and effect• ASCI CT«.,r License Number 4,7r 330 7� Lic ClassC� �•' +�d 3. 53.70 -- D I ITEMS Contractor d 1r1+1Ue-t1_SAA 5 Date- 9S TOTAL 53 m,90 8 ❑ I am exempt under Sec Plan check fee CHECK 53.90 p B&P C for this reason PERMIT ISSUING FEE$ O` CliNGE Date TOTAL FEE �O Wd Signature OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT 00-0001 I' ' Z I hereby affirm that I am exempt from the Contractor's License Law NAME M fi Q ^' r //�p D 1465 j tc UVU Ami V� L for the following"reason (Section 7031 5,'Business and Professions /v V ( 't0,! tit f 1 v Code) ADDRESS/ - ' ❑ I,'as owner of the property, or my employees with wages "� O �V i as their sole compensation, will do the work and theCITY - TEL NO structure Is not Intended or offered for sale (Section 7044, �! Business and Professions Code) OWNER r . ❑ 1, as owner of the property, am exclusively contracting MAIL //��A l /y� - with licensed5/contractors to construct the project (Sec- ADDRESS ' tion 7044, Business and Professions Code) CONSTRUCTION LENDING AGENCY CITY TEL NO hereby affirm that there Is a construction I •lending agency for CONTRACTOR 1 D I performance of the work for which this permit Is Issued D of-M-1 ' LAc (Sec 3097,Civ C) ; ADDRESS '2 �/ Lf - Lender's Name CITY ®,Q.< TEL NO /J77 , Lender's Address STATE , LIC 7 I certify that I have read this application and state that the above LICENSE NO a z CLASS C 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 the above-mentioned property for-in pection purp es SEE REVERSE FOR EXPLANATORY LANGUAGE ,'SIGNATURE O/PP CANT OR AG DATE-