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HomeMy Public PortalAbout8922 LONGDEN AVE_Mechanical__ WORKERS' COMPENSATION DECLARATION APPLICATION FOR PERMIT 1•hereby.affirm,that I have a certificate"of consent to self insure, or a certificate df Workers' Compensation Insurance, 76A3HEATING - VENTILATING - AIR CONDITIONING or a certified copy thereof (Sec. 3800,'Lab. C.) 20-00 4C vi,,��`�-.�� �j��� 20-0046 DPW 9/88 - Policy No��s�l�i��fompany�;�l (� 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 //�� p- tion department. ADDRESS ,2q.; M G�ys2 T C, q (PRINT OR TYPE ONLY) Date �� I / Applicant LOCALITY G NO. TYPE OF APPLIANCE OR EQUIPMENT FEE �LE CERTIFICATE OF EXEMPTION FROM WORKERS' I��/� 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.) L 1 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 BOILERBTU ✓J C 'so'as to become subject to the Workers' Compensation LOWS. APPROVALS DATE INSPECTOR'S SIGNATURE Date Applicant COMPRESSOR, BTU '7Odw �� � 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 VA ATION with comply with such provisions or this permit shall be deem- ed revoked. 1 FURNACE: FAUG AVITY 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 Lic. Class ► a �� (f� 0 Contractor ay' ` s' -"Q Date Elam exempt under Sec. O Plan check fee u W B.&P.C. for this reason. 3 _ H Date: PERMIT ISSUING FEE $ Z TOTAL FEE 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 Professions Code): �• I, as owner of the property, or my employees with ADDRESS- wages as their sole compensation, will do the work andi�;(; the structure-is not intended or offered for sale(Section CITY. TEL. NO. , 7044, Business and Professions Code). OWNER. /� 3370` 37.[10 I, as owner of the property, am exclusively contracting ��" 1 1TENS with licensed contractors to construct the project (Sec- MAIL tion 7044, Business and Professions Code). ADDRESS -1 AL 7 F ® 0 p CONSTRUCTION LENDING AGENCY / CITY TEL. NO. I hereby affirm that there is a construction lending agency for —�7 ',.HE:_.1V% '(,0 0 the performance of the work for which this permit is issued CONTRACTOR (Sec. 3097, Civ. C.). €ANG °ifll ADDRESS Lender's Name CITY TEL. NO. I-hl s#_ i Lender's Address •)JUU I�t1JO 110/15/90 I certifythat I have read this application and state that the STATE LIC. 7 :h s q�;1.=a,� pP LICENSE NO. CLASS !'F1 d .1.°Ji 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 upo ov a 'pned rty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Age Date ©s ^{ tk' COMPENSATION DECLARATION APPLICATION FOR PERMIT .I�heraby �ffirm irm that I have o certificate of consent to self , insure, or a certificate of Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING or a certified copy thereof (Sec. 3800, Lab . C.) 76A364C Policy No.,����Cofh /te/pai 'ny 20-0046 DPW 9/88 • �'�""-` . XL Certified copy is hereby furnished. COUNTY OF LOS ANGELES. BUILDING AND SAFETY El Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING cc�� Tion department. ADDRESS �wLa B 7 �• (PRINT OR TYPE ONLY) Date rD �—20-Applicant / LOCALITY ?x7 opoaG �1/ NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST COMPENSATION INSURANCE CROSS ST. eCye � (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 I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner 3�a�� so as to become subject to the Workers' Compensation Laws. BOILER, BTU APPROVALS. DATE INSPECTOR'S SIGN TURE 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 VA ATION 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 9 HEATER: SUSPENDED UNIT— (commencing with Section 7000)of Division 3 of the Business WALL and Professions Code,and my Iiceense is in full force and effect. s Y��J a CL License Number J Lic. Class , Its O V Contractor Date cc ❑ I am exempt under Seca ~ O Plan check fee — V W B.&P.C. for this reason. Date: PERMIT ISSUING FEE $ �3 — Z Signature 7—TOTAL FEE 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 Professions Code): ADDRESS F-1 1, as owner of the property, or my employees with wages as their sole compensation, will do the work and CITY TEL. NO. tt�•1•i a the structure is not intended or offered for sale(Section 7 7044, Business and Professions Code). OWNER ;I 7-7 I ❑ I, as owner of the property, am exclusively contracting 1 ITENS with licensed contractors to construct the project (Sec- MAIL tion 7044, Business and Professions Code). ADDRESS TOTAL 37 - 00 CONSTRUCTION LENDING AGENCY CITY TEL. NO. 7 I hereby affirm that there is a construction lending agency for -Z'7 CHECK 3 .(-Ti- the performance of the work for which this permit is issued CONTRACTOR , {y:HIANGE f1i (Sec. 3097, Civ. C.). n' ADDRESS Lender's Name 0000-0001 ) ♦. CITY TEL. NO. lltl —J Irl t i li`15/90 Lender's Address I certifythat I have read this application and state that the STATE LIC. '-i ° �i PP LICENSE NO. CLASS �1 � ���{�`•- 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 upo ove- nti ned perty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent Date WORKERS' COMPENSATION DECLARATION APPLICATION FOR PERMIT I heneby-affirm that I have a certificate of consent to self insure, or a certificate of"Workers' Compensation Insurance, ora certified copy thereof Sec. 3800 a C.) 76A364C! HEATING - VENTILATING - AIR CONDITIONING 20-0046 DPW 9/88 Policy No� .�� mpany t=7 ® Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY F7Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING tion department. ADDRESS (PRINT OR TYPE ONLY) ' P , Date (� —�� _` O Applicant QCIY LOCALITY NO. TYPE OF APPLIANCE OR EQUIPMENT FEE, G CERTIFICATE OF EXEMPTION FROM WORKERS' —� NEAREST COMPENSATION INSURANCE CROSS ST. �5,�7p (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 BOILERBTU so as to become subject to the Workers ,Compensation Laws. APPROVALS DATE INSPECTOR'S SIGNATURE Date Applicant / COMPRESSOR, BTU ROUGH Z NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL lam Z Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER vA6bATION with comply with such provisions or this permit shall be deem- ed revoked. FURNACE: FAU GRAVITY _ LICENSED CONTRACTORS'DECLARATION FLOOR BTU 7,1—ow-0 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� Lic. Class' , o 0 Contractor .Date 9/17 � O ElI am exempt under Sec. Plan check fee W B.&P.C. for this reason. CL PERMIT ISSUING FEE $ 3 Z Date: _ TOTAL FEE Signature OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT I hereby affirm.that I am exempt from the Contractor's License Low for the following reason (Section 7031.5, Business and NAME Aw Professions Code): ADDRESS I, as owner of the property, or my employees with ❑ A wages as their sole compensation, will do the work and 1�. •1°S NO. the structure is not intended or offered for sale (Section CITY TEL. X307�-a s — .-.- 7044, Business and Professions Code). °�°`,,,1 OWNER ❑ ®� D I, as owner of the property, am exclusively contracting I TTEN with licensed contractors to construct the project (Sec- MAIL tion 7044, Business and Professions Code). ADDRES TOTAL 3 - 00 CONSTRUCTION LENDING AGENCY r� �/ CIT �� TEL. NO. 1•F7 {:ft 7.I �l I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued CONTRACTOR poll.(Sec. 3097, Civ. C.). CHANr+ut °`!1 i ADDRESS , Lender's Name CITY TEL. NO. 31310—f,)I0001 10 j /t 0 Lender's Address STATE LIC. 33301 -14���•++ '•'' I certify that I have read this application and state that the LICENSE NO. CLASS H{ 1i 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 u h abo e-mentione roperty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agen Date ©s