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Home My Public Portal About9579 LAS TUNAS DR_Mechanical__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT I hereby affrrm that I have a certificate of consent to self Insure, or a certificate of Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING or certified co y thereof (Sec 3800, Lab C ) 76A364C I WC.1.�Of�d3 3 pA O�Sfp� CE-818(REV 10/81) Policy No-Company111` Certified copy is hereby furnished COUNTY OF LOS ANGELES / r BUILDING AND SAFETY ❑ Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING �� tion department ADDRESS � T A5 �/ (PRINT OR TYPE ONLY) ] Date 3--l-9—OK Applicant LOCALITY NO TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST COMPENSATION INSURANCE ABSORPTION UNIT, BTU CROSS ST � LeC4T 'e>Lvd, DISTRICT N (This section need not be completed If the work involved by O PR CESSED 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 'a C F::1 S 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 OR'S SiG Tu RE r� Date-3--294-4 Applicant I ' COMPRESSOR, BTU 3�� ROUGH NOTICETO APPLICANT If, after mating this Certificate of VENTILATION SYSTEM FINAL Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- E'VAPORATIVE COOLER VALID I with comply with such provisions or this permit shall be deemed revoked FU NACE FAU GRAVITY LICENSED CONTRACTORS DECLARATION FL R BTU c � I hereby affirm that I am licensed under provisions of Chapter 9 / HEATER SUSPENDED-UNIT- (commencing USPENDED UNIT /U�� (commencing with Section 7000) of Division 3 of the BusinessWALL and Professions Code,and my license is In full force and effect License Number 3961 Llc Class Contractor A�rAAiE Date a��¢' ❑ I am exempt under Sec Lse Plan check fee B &P C for this reason PERMIT ISSUING FEE $ �O g Date Signature TOTAL FEE 0 SO 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) ❑ 1, as owner of the property, or my employees with ADDRESS ( T wages as their sole compensation,will do the work and CITYTEL NO yv the structure Is not intended or offered for sale (Section ' 7044, Business and Professions Code) �+ ❑ OWNER ( AU.E S!N I, as owner of the property, am exclusively contracting pwith licensed contractors to construct the project (Sec- MAIL / 0 tion 7044, Business and Professions Code) ADDRESS LAKE AuE CONSTRUCTION LENDING AGENCY CITYA TEL NO I hereby affirm that there Is a construction lending agency for the performance of the work for which this permit Is issued CONTRACTORS-0 , d S-0 (Sec 3097, Civ C ) G r ADDRESS 33 Z3 —f=JF/VS S� 3Q A Lender's Name CITY J_AC TEL NO Z�4'73`3 Z- Lender's Address STATE LIC I certify that I have read this application and state that the LICENSE NO ��p�-� CLASS 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 u on the abov m tioned property for Inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent Date WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT h`hereby affirm that I have a certificate of consent to self 'S ora c, ora certificate of Workers' Compensation Insurance, 76A364C HEATING - VENTILATING - AIR CONDITIONING `{ or a certified copy thereof (Sec. 3800, Lab. C.) � CE-818(REV. 10/81) Policy No. Company 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. ADDRESS (PRINT OR TYPE ONLY) Date Applicant LOCALITY NO. TYPE.OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE 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. o PtOCESSED BY the permit Is for one hundred dollars($100)or less.) AIR HANDLING UNIT, CFM 1 certify that in the performance of the work for which this E-. ' '^ AV �.• permit is issued, I shall not employ any person in any manner BOILER, BTU so as to become subject to the Workers'Compensation Laws. APPROVALS DATE INSPECTOR'S SIGNATURE Date Applicant COMPRESSOR, BTU "rn 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 VALIDATION' with comply with such provisions or this permit shall be _ deemed revoked. FURNACE: FAU E3RA1Ta LICENSED CONTRACTORS DECLARATION FLOOR BTU I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT HEATER: WALL d (commencing with Section 7000) of Division 3 of the Business and Professions Code,and m license is in full force and effect. y O u License Number Lic. Class , LU Contractor Date ❑ } I am exempt under Sec. � Q Plan check fee JIM B.&P.C. for this reason PERMIT ISSUING FEE $ t,% Date: Q " d 's u�i Signature TOTAL FEE _ UJ OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT 'i e � 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 and the structure is not intended or offered for sale(Section CITY 3 TEL. NO. f 7044, Business and Professions Code). OWNER t .. ❑ I, as owner of the property, am exclusively contracting < with licensed contractors to construct the project (Sec- MAIL y"+ tion 7044, Business and Professions Code) " ADDRESS CONSTRUCTION LENDING AGENCY CITY-,,.- TEL. NO. I hereby affirm that there is a construction,Ie' nding agency for pop.the performance of the work for which his permit is issued CONTRACTOR ' �i ' (Sec. 3097, Civ. C.). ADDRESS Lender's?Name LSTATE TEL. NO. Lendees-,Address - LIC. I certify that I have read this application and state that the NO. CLASS 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 s Signature of Applicant or Agent Date - � 3u>