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HomeMy Public PortalAbout8916 LONGDEN AVE_Mechanical__ ' WORKERS' COMPENSATION DECLARATION I''hereby affirm that I have a,certificate of consent.to self �P P LC A NF O R P E R NT Insure, or a certificate of Workers' Compensation Insurance, 76A364C bEAVIRIG - VENTILATING - AIS CONDITIONING or 6 certified copy thereof Set 3800, Lab C ) Pohcy an a2 20-0046 DPW 9/88 p Y COUNTY OF LOS ANGELES •_,�-Certified copy is hereby furnished BUILDING AND SAFETY, 0 Certified copy Is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING tion department ADDRESS [7 ,,/_ - (PRINT OR TYPE ONLY) �• C Date �0 9a A licant Q LOCALITY D PP NO TYPE OF APPLIANCE OR EQUIPMENT FEE r L�' cn-� CERTIFICATE OF EXEMPTION FROM WORKERS' 1 NEAREST ' COMPENSATION INSURANCE CROSS ST `This'secticn 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.) I'certify that in the performance of the work for which this AIR HANDLING UNIT, CFM �! 71� permit is issued,'l shall not employ any person in any manner �Jil C/ ,.so as to become subject to the Workers'Compensation Lbws BOILER, BTU APPROVALS DATE INSPECTOR'S SIGNATURE 5 Date Applicant COMPRESSOR, BTU 36o" � ROUGH !q - •� -'`�- / ' "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 IfA. E1ATION with comply with such provisions or this,permIt shall be deem- ed'revoked FURNACE FAU GRAVITY LICENSED CONTRACTORS DECLARATION. FLOOR BTU •1 hereby affirm that I am licensed under provisions of Chapter 9 HEATER SUSPENDED UNIT WALL • (commencing with Section 7000)of Divisiont3 of the Business - , and,Professions Code,and my license is in full force and effect License Number 5` _8 Lic Class D ° Contractor a Q Date ❑ I &n exempt under Sec 0 • Plan check fee " B 8P C for this reason H Date PERMIT ISSUING FEE Z Signature TOTAL FEE 3 OWNER-BUILDER DECLARATION • PAN 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) II �1 F-1 1,I, as owner of the property, or my'employees with wages as their sole compensation,will do the work and ANT, CITY TEL NO OWNER • the structure is not Intended or offered for sale(Section - ' 7044, Business and Professions Code) 23I37 37.010 ❑ I, as owner of the property, am exclusively contracting I ITEMS , with licensed contractors to construct the project (Sec- MAIL LI�A� _ tion 7044, Business and Professions Code) ADDRESS CONSTRUCTION LENDING AGENCY CITY TEL NO TOTAL 00 I hereby affirm that there is a construction lending agency for 1r•�i =7aChI the performance of'the work for which this permit is issued CONTRACTORt (Sec 3097, Civ C ) D ���HAWt s 0101 ADDRESS Lender's Name +, r q ,� CITY TEL.NO 0000-0001 LII 15/3 i Lender's Address STATE LIC `' I certify that I have read this application and state that the L=EINO C LASS- - `.13,33 1 AM11:337 above Information is correct I agree to comply with all County ordinances and State jaws relating to building construction, and hereby authorize representatives of this County to enter uVon-l_Vaboye-mentionA property for inspection purposes - - SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Age Date �s WORKERS' COMPENSATION DECLARATION AFOR 'I hereby affirm that I_have a certificate of consent to self IrPP L� CAYM 'T (I�N lr PER�u N Ihsure,br a certlflcate of Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING or a certified copy thereof (See ,3800, Lob C ) 76A364C l3 �,_ � � �i ® 20-0046 DPW 9/88 Policy No ompany�-� --� ® 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 Qg(6 T C tion department a (PRINT OR TYPE ONLY) ADDRESS � „ Date 10 —I(—& Applicant 'C LOCALITY C/j.� NO ' TYPE OF APPLIANCE OR EQUIPMENT FEE L��/ ,� ,, CERTIFICATE OF EXEMPTION FROM WORKERS'/—, ORKERS'� � NEAREST Cc7 .��" 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.) I certify that in the performance-of the work for which this AIR HANDLING UNIT, CFM permit is Issued, I shall not employ any person in any manner + so as to become subject to the Workers' Compensation Laws BOILER, BTU - APPROVALS DATE INSPECTOR'S SIGNATURE / - COMPRESSOR, BTU G ROUGH Date Applicant -,"NOTICE TO APPLICANT If, after making this Certificate of VENTILATION SYSTEM FINAL Exemption, you should become subject to the Workers' V '1 Compensation,provisions of.the.Labor Code, you must forth- EVAPORATIVE COOLER VAL ATION with comply with such provisions or this permit shall be deem- ed revoked ' FURNACE FAU GR ITY 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 full force and effect License Number�'TT34 " �'Lic Class D O U Contractor, �I "s ate /�✓/_�a IM ❑ I am exempt undSe'er S • O Plan check fee W B&P C for this reason' H Date PERMIT ISSUING FEE $ �.3 z �. TOTAL FEE Signature I I OWNER-BUILDER DECLARATION PLAN CHECK'APPLICANT •1 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) ADDRESS I,'as owner of the property, or'my employees with JL v wages as their sole compensation,will do the work and CITY TEL,NO ACCT.ir the structure Is not intended or offered for sale (Section ^ 7044, Business and Professions Code) il07 37 �0 OWNER � ° ❑ I, as owner of the property, am exclusively contracting , -1 ITEMS with licensed contractors to construct the project (Sec- MAILA tion 7044, Business and Professions Code) - ADDRESS (ri �' TOTAL 37 = 00 CONSTRUCTION LENDING AGENCY CITYl TEL NO - / ; I hereby affirm that there is a construction lending agency for p CHECK =7•E Il= the performance of the work for which this permit is Issued CONTRACTOR DINE (Sec 3097, Civ C ) ^ ADDRESS Lender's'Name CITY VV TEL NO 1301313-1001 10/15/90 Lender's Address Y - •• ' ht °? I certify that I have read this application and state that the STATE LIC LICENSE NO CLASS `'t`10� AM11``'%' 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 po u $ove- entioned pr rty for inspection purposes - ••^ ,- • _�/_96 SEE REVERSE FOR EXPLANATORY LANGUAGE AO Signature of Applicant or Age Date ©5 WORKERS' COMPENSATION DECLARATION ya PP C /,a y� N 2®R (�ERNT "4 fTereby=affirm that I have a certificate of consent to self C�1 L� �blr�'i1 ll ll�l I!- 7" 0 Il Insure, or a certificate of Workers' Compensation Insurance, HEATING - NEId4ILATI ING - AIR CONDITIONING k or'dcertified of76A364C copy thereof 3800, Lab C ) 20-0046 DPW 9/88 Policy to_, ,���7 Com pan COUNTY OF LOS ANGELES BUILDINGAND SAFETY r Certified copy Is hereby furnished Certified copy is filed with the county building mspec- FOR APPLICANT TO FILL IN BUILDING ,p tion department ADDRESSC Q (PRINT OR TYPE ONLY) Date -f I^/ a Applicant , LOCALITY I - NO TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' '•� ORESST d, COMPENSATION INSURANCE (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.) „ GAG AIR HANDLING UNIT, I,certify that in the performance of the work for which this CFM Q ,• permit Is issued, I shall not employ any person in any manner, [ _ ' Ix BOILER, BTU iso as to,become sublect to the Workers' Compensation Laws - _ APPROVALS DATE' INSPECTOR'S SIGNATURE Date Applicant ` COMPRESSOR, BTU .36y�t7 ROUGH Z• S%g( 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 VA ATION •with comply with such pr'ovisions'or this permit`sfiall be deem- ed'revoked FURNACE FAU G A ITY LICENSED CONTRACTORS DECLARATION FLOOR. BTU. � r� ' 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 Iicense.is ImfulI force and effect SS gIL license Number. �3tic Class �. D O Contractor Date m,exempt under Sec O ' + Ill- Plan check fee u B&P C for this reason d • . • PERMIT ISSUING FEE _ H Date ZTOTAL FEE . r Signature OWNER-BUILDER DECLARATION PIAN CHECK APPLICANT ti I hereby affirm that I am exemptif om•the Contractor's License Law,for the following reason (Section 7031'5, Business and NAME' D r Professions Code) I, as owner of the property, or my employees with ADDRESS _ wages as Their sole compensation,will do the work and CITY TEL NO Aur.i d°� - • th"e structure is not intended or offered,for sale (Section 7044, Business and Professions Code) L f'' _207 u! ° OWNER. I, as owner of the property, am exclusively contracting s r with licensed contractors to construct the project (Sec- MAIL 1 i t�t i`' tion 7044, Business and.Professions Code)' ADDRESS CONSTRUCTION LENDING-AGENCYpA J > TOTAL 37 ® 00 CITY i - TEL NO a��'" t I hereby affi'm that there is�a,construction lending agency for �'y' - ,�t.I'{IrCK '° �i 'the performance of-the work for which this permit is issued CONTRACTOR °;il'I (Sec 3097,.Civ C ) CHANGE ADDRESS r Lender's Name c�n� Lender's Address CITY TEL NO 00010-00Cl1' 10/1 t, 7ti' STATE LIC _ s° I certify that I have read this application and state that the LICENSE NO o CLASS above information is correct I agree to comply with all County -, ordinances and State laws relating to building construction, j and hereby, authorize representatives of this County-to enter upo aov mened perry for inspection purposes -" SEE REVERSE FOR EXPLANATORY LANGUAGE M N Signature of Applicant or Agent Date '. - _ ®s r A,. ,