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Home My Public Portal About9520 LAS TUNAS DR_Mechanical__ t1 WORKER'S COMPENSATION DECLARATION 20-0046 DPW 9%89 APPLICATION FOR PERMIT 76A264C_ - • _ LIME .GREEN, �.. I hereby affirm that- have a certificate of'consent,to self insure, or a certificate oUWoi`ker's Compensation Insurance, or'a certified HEATING-VENTILATING'-AIR CONDITIONING. copy thereof(Sec.3800 Lab:C.)- u Policy No 0�7V 7��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 building inspection FOR APPLICANT TO FILL IN ADDRE S _ department. .. (PRINT OR TYPE ONLY).., _ LOCALITY Date T// Applican NO. • TYPE OF-APPLIANCE OR EQUIPMENT FEE` CERTIFICATE OF EXEMPTIO O _ O KER NEAREST CROSS ST: COMPENSATION RANCE ABSORPTION UNIT,BTU This section need not be com i d if the work involved b the ASSESSOR ( p Y MAP BOOK PAGE PARCEL permit is for one hundred dollar ($100)or less.) AIR HANDLING.UNIT,CFM DISTRICT NO. PROCESSED BY I certify that in the,'performance of the work for which this permit is issued, I shall not employ'any person in any manner so.as to BOILER,BTU �Q . become subject to the Workers'.Compensation Laws. COMPRESSOR,BTU APPROVALS. DATE INS P OR'S SIGNATURE Date Applicant VENTILATION SYSTEM NOTICE TO 'APPLICANT: if, after making•this Certificate of ROUGH 1 ,. �• Exemption,you should become subject to the.Workers'Compensation EVAPORATIVE COOLER provisions of the Labor Code, you must forthwith comply with such FINAL provisions or this permit shall be'deemed revoked. FURNACE: FAU GRAVITY LICENSED CONTRACTORS DECLARATION'. FLOOR BTU VALIDATION I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT (commencin'g with Section 7000)of Division 3 of the Business and HEATER: WALL Professions Code, and my license is in full force and effect. License Number 2— Lic.Class_ v ,n r ACCTog . . a Contractor.�•/ . S� rF ate 1 O Plan.check fee 3303 107.10 U I am exempt under.Sec._ • , F 0 B.&P.C.for this reason PERMIT ISSUING FEE$ Q TOTAL 10 , c) 1 .ITEMS . Date: TOTAL.FEE ®. U1 Signature' CHECK 107.10 � OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT CHANGE .00 Z I hereby affirm that I am exempt from the Contractor's License Law NAME G Lt for the following reason(Section 7031.5, Business and Professions Code): ADDRESS n {}-0001 11/22/9 . C{OCICI 1, as owner of the property, or my employees with wages, 7t i M •� as.their sole compensation,`will do the work'and the CITY TEL.NO. 3415 1 AM11�3? structure is not intended or offered for sale (Section 7044, Business and Professions Code). i' OWNER. I, as owner,of the property, am exclusively contracting MAIC with,licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY CITY TEL:NO. ( ) ruction lending agency for 'he performance affirm that there o a const p CONTRACTOR % 2 I he erformance of the' for which this ermrt Is issued v ♦ _- Sec.3097,Civ. C.. / s ADDRESS Lender's Name CITY. TEL:NO. i ` • Lender's Address STATE, LIC: I certify that 1.have read this application and state that the above uCENSE:No. 'L CLASS " 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 purpose SEE REVERSE FOR EXPLANATORY LANGUAGE SI RE OF APPLICANT OR AGENT DATE F ;, ' WORKER'S COMPENSATION DECLARATION 20-0046 DPW 9/89 � (hereby affirm that I have a certificate of consent to self insure, APPLICATION ION FOR PERMIT 76A364C UM E GREEN r a certificate of Worker's Compensation Insurance, or a certified F!s HEATING:=VENT`ILATING -AIR CONDITIONING jopy thereof(Sec.3800 Lab.C.) jcy 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 building inspection FOR APPLICANT TO FILL IN ADDRESS department. (PRINT OR TYPE ONLY) 'f Date ApplicantLOCALITY NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST CROSS ST. COMPENSATION INSURANCE, ABSORPTION UNIT,BTU ASSESSOR (This section need not be completed if the work involved by the MAP'BOOK PAGE PARCEL permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO. PROCESSED BY 1 certify that imthe'performance of the work for which this permit ' is issued, I shall not employ any person in any manner so as to BOILER,BTU tt become subject to the Workers' Compensation Laws. COMPRESSOR,BTU r t O3.00 C _ APPROVALS DATE 'INSPECTOR'S SIGNATURE Date � Applicant VENTILATION SYSTEM p�S � - NOTICE TO APPLICANT: If, after m king this Certif' ate of ROUGH. 1?�/ Exemption,you should become subject to the Workers'Co saes EVAPORATIVE COOLER provisions of the Labor Code, you must forthwith comply with such FINAL provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY LICENSED CONTRACTORS DECLARATION FLOOR. BTU D 6 O� VALIDATION I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT (commencing with Section 7000)'of Division 3 of the Business and HEATER:. WALL iProfessions Code,and my license is in.full force and effect. �v License Number ` g Lic.Class � (/v ;,r-`tl:_ O Cohtractor Date .1'LJ I V ❑ 1 am exe pt under Sec. 41 Plan cheek fee TOTAL yL 32 1'= 401 q: B.&P.C.for this reason PERMIT ISSUING FEE$a. to .41 ? L -C TOTAL FEE �1 .I-Ir;h( I: .I': W ` Date: _ _ Signature PLAN CHECK APPLICANT' N OWNER-BUILDER DECLARATION I I_'_il —¢ hereby affirm that I am exempt from the Contractor's License Law. NAMEc for the following reason (Section 7031.5, Business and Professions , +-• �-'-° Code): ADDRESS ❑ I, as owner of the property„or my employees with wages as their sale compensation, will do the work and.the CITY TEL.NO. structure is not intended or offered for sale (Section 7044, Business and Professions Code). OWNER_ ❑ I, as owner of the property,lam exclusively contracting MAIL with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY CITY ',TEL.NO.' 1 hereby affirm that there is a construction lending agency for' CONTRACTOR the performance of the work for which this permit Is issued _ (Sec.3097, Civ.C.). ADDRESS lLAS culAc P9__ ;. Lender's Name CITY�� TEL.NO. _ , .... Lender's Address STATE l 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 representatives of this County to enter upon the above-mentioned property for 'nspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE ' G ATU E OF APPLICANT OR AG71 DAl