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Home My Public Portal About9038 LONGDEN AVE_Mechanical__ 'WORKER'S COMSATION DECLARATION 204)046 DPW 9/89 I hereby affirm that Ihave a certificate-of consent to self Insure, 76A364C FOR PERWT U E GRFEN - _ or a certificate of Workers Compensation Insurance, ora certified HEATING-VENTILATING-AIR CONDITIONING copy thereof(Sec 3800 Lab C) - Polley No Company COUNTY OF LOS ANGELES - DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV. L ❑ Certrfied copy is hereby furnished r ❑ CertrfFOR APPLICANT is filed with the county building Inspection. FOAPPLICANT TO FILL IN BUILDING �( � � L-C'J�1Jt�E department (PRINT OR TYPE ONLY) '�,,,- ✓%�' , Date Applicant LOCALITY NO TYPE OF APPLIANCE OR EQUIPMENT � FEE ,NEAREST CROSS CERTIFICATE OF EXEMPTION FROM WORKERS' ! CROSS ST COMPENSATION INSURANCE ABSORPTION UNIT,BTU ASSESSOR _ (This section need not be completed If th_e work Involved by the _ MAP BOOK PAGE ,5' PARCEL, permit Is for,one hundred dc4lars'(5100)'or'lesa.) AIR'HANDLING UNIT,CFM DISTRICT NO PROCESSED 13v I certify that in theperformance of'the work for'which-this+permit Is Issued, I shall not employ any person In any manner so as to,' BOILER,BTU Al v ^ a become subject to the Workers"Corn pehsation Laws f �O R ). COMPRESSOR,BTU V/ V'7'7 p O ^ AP=PROVALS DATE ;•, INSPECTOR'S SIGNATURE• ,"• Date ''`' ` Applicant _ _ VENTILATION SYSTEM ° NOTICE-TO APPLICANT'-If,,after making this Certificate of ROUGH 1� •Exemption,you should become subject,to,the,Workers'Compensation - EVAPORATIVE COOLER , d provisions of the•Labor Code, you must forthwith,comply,with such '' d FINAL Mk4 _L provisions or this permit shall be deemed revoked '"/ FURNACE - FAU Af GRAVITY'' a LICENSED CONTRACTORS DECLARATIONf / '•AFLOOR BTU ��•BtlD d "VALIDATION ' I hereby,,pffirm that I.am licensed,under provisions ofiChapter 9 HEATER SUSPENDED UNIT (commencing'with-Section-7000),gf Dlvision'3 of•the;Business and WALL i Professions Code,and my license,is In full force and effect F` License Number v' Lic�Class - 'Contractor r - 'y'• - Date• ,��' ..'i• .. - ,. •- �' - � •/• .• •s. a ❑ m r` s Al Plan check fee . I '`_ I aexempt under Sec- B&P C for this reason ;. '}', PERMIT ISSUING+EE O Date ; „ TOTAL FEE r ' ;z m F . v__. . ;—— W, Signature 74 + - F e, OWNER-BUILDER DECLARATION " PLAN CHECK APPLICANT t i _ { ', (n x: ,• I hereby affirm that I am exemptfrom the Contractor's License Law NAME.' for the following reason (Section'7031 5;Business and,Professions D ►tl•I T.Ir Code) ADDRESS P u _ -;30 7 owner of the pro erty, or my emp toyees'with'wages y75,45 M as their,sole compensation, will do,the work,an ,iliie CITY _ TEL NO e- T w j ITEMS " structure-Is not Intended'or'offered for sale (Section 7044, 11.iTr7L; Business and'P,rofessions Code) WNER t/�h� °+ �'ZC' �,«—�� ,1 ,--8 m -n ❑ o G' I, as owner of the property, am exclusively contracting MAIL " ' '.Yr`• CHECK', q ro c with,licensed'contractors'to construct the project (Sec- ADDRESS °r ��' a;' CHANGE oL�I"^ tion 7044,.Business and Professions Code) P r,. ryVGq CONSTRUCTION LENDING AGENCY CITY TEL NO r' l hereby affirm that there is'a construction lending agency for } ��'y ��11''"'1�,,'1yii i GG I performance of the work for which this permit Is Issued CONTRACTOR D _, VI,JL3 'L1rJtJ1 .,- 4f1�?!73 (Sec 3097;`Cry C) a„ ryes F •' I ADDRESS 77• tilt�v�ia1 ",r7 Lender's Name Cdr t/i�v .� • a, CTEL O N Lender's Address�L D' "- `'•� '" S ATE „ ,LIC certrfy that I have read,this,apphcation and state that the above LICENSE NO CLASS information iS correct I agree to`comply-With all County,ordinances ' and State laws relating to•bwlding construction,and hereby authorize representatives of this,County'to•enter upon the abov6.:menti6ned µ Y,t property for inspection purposes '; '•; /► C �� SEE REVERSE FOR EXPLANATORY LANGUAGE ,c SIGNATURE OF APP I ANT OR ENT - DAT • y}e '' dam• - WORKER'S COMPENSATION DECLARATION. 200046 DPW 9/89 ��®� ®� �� GREEK, 76A384C I•hereby affirm that I have a certificate of consent to self'Insure, or a certificate bf Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING copy thereof(Sec 3800 Lab C) Policy No Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV. ❑ Certified copy Is hereby furnished, ❑ Certified copy Is filed with the county budding Inspection FOR APPLICANT TO FILL IN BUILDINGT Gam/ I .� department (PRINT OR TYPE ONLY) ADDRESS d v 44—v AV 6-V i6w - Date Applicant NO' TYPE OF APPLIANCE OR EQUIPMENT _ FEE LOCALITY •1710ZI CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST : COMPENSATION INSURANCE CROSS ST 1 - - ABSORPTION UNIT,BTU , (This section need not be completed if the work Involved bythe ASSESSOR MAP BOOK- PAGE PARCEL permit is for one hundred dollars($100)or les's.) AIR HANDLING UNIT,CFM DISTRICT NO PROCESSED BY I certify that In the performance of the work for which this permit Is issued, I shall not employ any person in any manner so as to BOILER,.BTU �� become subject to the Workers;Compensation Laws COMPRESSOR,BTU APPROVALS DATE INSPECTOR'S SIGNATURE Date Applicant, - VENTILATION SYSTEM NOTICE TO APPLICANT If, after making this Certificate of ROUGH' Exemption;you should become subject to the Workers' Compensation EVAPORATIVE COOLER Y provisions of the Labor Code, you'must forthwith comply with such FINAL provisions or this permit shall be deemed revoked FURNACE FAU GRAVITY LICENSED CONTRACTORS DECLARATION FLOOR BT VALIDATION, I hereby affirm that I am licensed,under provisions of,Chapter 9 SUSPENDED UNIT (commencing with Section 7000) of Division 3,of the Busmess and HEATER WALL , Professions Code,and my license Is In full force and effect License Number LIc Class Contractdr Date '' D - O ❑ � I Plan check fee = I am exempt under Sec ' , B&P C•for this reason PERMIT ISSUING FEE$� �" = U Date TOTAL FEE a Signature CL OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT Z I hereby affirm that I am exempt from the Contractor's License Law NAME /0 for the following reason (Section 7031 5, Business;and-Professions `C� ��r�� L D Code) F� �-{f�, v 3� �� V 2Z 73 ?�o�_•: i - ADDRESS I, as owner of the property, or my employees with wages as their sole-compensation,-will do the work and the CITY _J_C-7Af PLbi, QJNO -f-5-L -6/< 1 1 TC.'F• structure Is not Intended or offered for sale-(Section 7044-, _hhjj _ Business and Professions Code) OWNER F� �^� L1„ �s_t I rtL 622'22. ❑ I, as owner of the property, am exclusively contracting MAIL With licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code) CITY - TEL NO ^ CONSTRUCTION LENDING AGENCY I hereby affirm that there Is a construction lending agency for CONTRACTOR D the performance of the work for which-this permit Is issued (Sec 3097,Civ C) :;5• / :i;I tj t:{r}�[ll� ADDRESS _ Ji i. _. LR. Lender's Name 's 12,1 t1 L_I a vi a CITY TEL NO - - Lender's Address STATE LIC �... I 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 ordinances and State laws relating to building construction,and hereby authorize T representatives of this County to enter upon the above-mention d property for Inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE SIGNATURE OF APPLICAFT OR AGENT DATE - '