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Home My Public Portal About9658 LIVE OAK AVE_Mechanical__ W IKER'S COMPENSATION DECLARATION 20-0048 DPW 9/89 O O p C N FOR O 2�p I herebl affirm that,l haveoa certificate of consent to self insure, 76A364C "��L��hQ��®II�1 I�®W �LSUIl��y Uvu or a.ee�h'tficate of worker's Compensation Insurance, or a certified HEATING VENTILATING-AIR CONDITIONING copy theredl($gc.3800 Lab.C.) " P❑olicy,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 BUILDING ADDRESS ' �� department. (PRINT OR TYPE ONLY). _ s Date ApplicantLOCALITY NO. TYPE OF APPLIANCE OR EQUIPMENT,, FEE _ CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST { COMPENSATION INSURANCE CROSS ST. 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($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO. - PROCESSED BY - - I certify.that in the performance of the work for which this permit is issued I shall not employ any,person in any manner so as to BOILER,BTU become subject to the Workers'Compensation Laws. r �Gdt�y -t c COMPRESSOR,BTU . APPROVALS DATE INSPECTOR'S SIGNATURE DateApplicant VENTILATION'SYSTEM NOTICE TO APPLICANT: If, after making this Certificate of ROUGH ?�ig Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER.. provisions of the Labor Code, you must forthwith comply,with suchFINAL ' provisions or this permit shall be deemed revoked. ] FURNACE: FAU GRAVITY . LICENSED CONTRACTORS DECLARATION, FLOOR BTU LIDA IOIN I.hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT (commencing with Section 7000) of Division 3 of the Business and HEATER: WALL Professions Code,and my license is in full force and effect. License Number Lic.Class i.1•I °,r a Contractor*" Date_ -� - O ❑ I am exempt under Sec. Plan Check fee 317 � '« °°i:) U 1 !i Ell B.&P.C.for this'reason PERMIT ISSUING,FEE$ eo O Date: TOTAL FEE _�I`E F1 m 00 U LU Signature. < A. l 7 l_I d OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT ; EI•eNGE °S It i Z I.hereby'affirm that'l am exempt from,the Contractor's License Law NAME ' .for the following reason (Section 7031.5, Business and Professions D `Y e): ADDRESS YCod 'i0I1``t i l SI S i y/ I, as owner.of the property, or•my employees with wages " as their sole compensation, will do the'work and the CITY TEL.NO. 5(-��°a iF`I :1o'rF structure is not intended or offered for sale (Section 7044, ` Business and Professions Code). ❑ 1, as owner-of the property, am exclusively contractingMAIL with licensed contractors to construct the project(Sec- ADDRESS SAM 166-Du tion 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY CITY TEL.NO. L I.hereby affirm that-there is.a construction lending agency for the.performance of the work for which this permCONTRACTOR it Is issued D %> (Sec:3097,Civ.C.). _ ADDRESS Lender's Name � n A S/ _ CITY TEL.NO. Lender's Addressa! �/TL/ STATE 11C. 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 constrtiction,and hereby authorize representatives of this Cpunty to enter upon the above-mentioned property for ipspection urposeS. SEE REVERSE FOR EXPLANATORY LANGUAGE SIGNATURE OF'AqLICANT OR AGENT DATE sORKER'SCOMPENSATION DECLARATION 20-0046 DPW 9/89 ��,��®^,; ®� ��nn�� MAE �RE �r. 76A364CD0wlu�u •I hereby affirm that I have a'certlflcate�of consent to self insure; o�8 ce�rGficate^of Worker's Compensation-Insurance, of a certified HEATING-.VENTILATING -AIR CONDITIONING copy thereof(Sec.3800 Lab. C.) . Policy Na. 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) r ,f Q` , i - Date Applicant LOCALITY - NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF.EXEMPTION FROM WORKERS' CROSSSSST 1 d CRST. COMPENSATION INSURANCE ABSORPTION UNIT,BTU (This section need not be completed if,the work involved by the MAP BOOK PAGE 7PARCEL. permit'is for one hundred dollars($100)'or+less) AIR HANDLING UNIT,CFM DISTRICT No. PROCESSED BY certify that in the performance of the work for,which this'permit ) is issued, I shall not employ any person in any manner so as to BOILER,BTU become subject to the Workers'Compensation Laws. COMPRESSOR,BTU APPROVALS. DATE INSPECTOR'S SIGNATURE Date � Applicant. VENTILATION SYSTEM NOTICE TO APPLICANT: If,-after making this Certificate of ROUGH 2� Exemption,you should•become subject to the Workers'Compensation EVAPORATIVE COOLER provisions of the Labor Code,.you must forthwith comply with such FINAL, provisions or this.permit shall-be deemed revoked. FURNACE: FAU - GRAVITY LICENSED CONTRACTORS DECLARATION FLOOR BTU LIDATIO I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT ,'(commencing'with Section 7000) of Division 3 of the Business and HEATER: WALL d(7 Professions Code,and my license is in full force and effect. License Number Lic.Class D o Contractor Date V ❑ I am exempt under Sec. Plan Check feecc BAP.C.for this reason PERMIT ISSUING FEE$ 0 Date:' U TOTAL FEE Q W Signature ... .: � (!1 OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT Z I hereby affirm that I;am exempt from the Contractor's License Law NAME for the following reason (Section 7031.5, Business and Professions D 1 Code): ,.:.;:, 4 ADDRESS Aio .,T.. I, as owner of the.property, or my employees with wages Ljf f as their sole compensation, ;will do the work and the CITY TEL.NO. 3307 structure is not intended or offered for sale (Section 7044, �- i' T TEI Business and Professions Code). OWNER f ❑ I, as owner of the property, am.exclusively.contracting MAIL TOT�I AL 25 00. with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code). CHECK CONSTRUCTION LENDING AGENCY CITY TEL.NO. " 1 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.). ::•_. ADDRESS -7q t ^ Lender's Name� LpF>�7�_ 11 r I Er al_!Ij—Ill II i 1 t :' 71_( `1 CITY 'TEL.NO. t5'� f I'� 7 t ' G2.b y J _ i/o aa:Il ._.� ,.. .Lender's Address �•' _ STATE ,LIC.. certify that I ha\Ye read this-application and state thae 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 or in pection piirposes. SEE REVERSE FOR EXPLANATORY LANGUAGE 14. J`z-) -7 � ., SIGNATOR FAPPLI AN O,AGENT . . DATE