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HomeMy Public PortalAbout9501-9503-9505 LONGDEN AVE_Mechanical__ WORKERS'COA71'ENSA'fION DECLARATION I CEA 818(2-80) A P P L;e C AT�®N FOR Il—E R WT I hereby affirm that I have v certificate of consent to self insure, or a certificate of Workers'Compensation Insurance,or p-IE:ATING_VE NTILATING-AIR CONDITIONING _ "fl a certified copy there o` cP 3800,Lab.C.) _ - Policy No. Companyr�^a�T ��'y ••�r� ��� �` ified copy is hereby furnished. it COUNTY OF LOS ANGEL�yS, �. B 15NG ARID SAFETY Certified copy is filed with the county building inspection BUILDING L5 r.I rtm //�� . FOR APPLICANT TO FILL IN DataApplicant_�S1 (PRINT OR TYPE ONLY) ADDRESS CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY COMPENSATION INSURANCE NEAREST (This section need not be completed if the work involved ABSORPTION UNIT,BTU CROSS ST. T�nI� ITGo� I / CL by tate permit is for one hundred dollars ($100) or less.) DISTRICT NO. PROCE D BY'.- 0 I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM permit is issued, I shall not employ any person in any manner O so as to become subject tq the Workers'Compensation Laws. BOILER,BTU APPROVALS DATE INSPECTOR'SSIGNATURE W Date Applicant Z COMPRESSOR,BTUG�— � ROUGH `er� N NOTICE TO APPLICANT: If, after making this Certificate ofVENTILATION SYSTEM Z Exemption, you should become subject to the Workers' FINAL_ Compensation provisions of the Labor Code, you must forth- E COOLER Nyith comply with such 'provisions or thEVAPORATIVE is permit shall be VALIDATION deemed revoked. FURNACE: F A U LICENSED CONTRACTORS DECLARATION FLOOR: BTU I hereby affirm that I am licensed under provisions of Chapter HEATER: SUSPENDED UNIT 9 (c9mmencing with Section 7000) of Division 3 of the Busi- WALL ness and Professions-Code, and my license is in full force and effect. License N. umtier_ PY-7 Lic.ClassC^ (3 Contractor � Date .. 0 lam a Mapt rom tlte'Iicensing requirements as I am a licensed architect.or a registered professional engineer 1Plan check fee 25%of above. acting in my professional capacity (Section 7051, Bus- iness and Professions Code). � PERMIT ISSUING FEE$ Lic,or Reg.NQ. Date TOTAL FEE HOME OWNER•BUILDER DECLARATION PLAN CHECK APPLICANT 1 hereby affirm that•I am exempt from- the Contractor's )NAME License Law for the following reason (Section 7031.5, Busi- ness:ind Professions Code): 1ADDRESS FJ I, as owner of the property,will do the work and the (CITY TEL.NO. structure is not intended. or offered,for sale (Section 1 7044, Business and Professions Code). I "3.7,2 2.A ❑ JOWNER I, as owner of the property, am exclusively contracting with licensed contractors to construct the project MAIL / /,SGT r/�,h #'o.a a a a a (Section 7044,Business and Professions Code). JADDRESS Z j. rrv�+ �L e� 6- '° �- CONSTRUCTION LENDING AGENCY �� CIT TEL.NO. 2- 68.50_ hereby th'd performance ofthre eulending a construction Work forwh ch th sermit is forCONTRACTOR °:°i�° 6 R 5 0 6 issued(Sec.3097,Civ.C.). lJ Q? 1 —82 Lender's Nanie '.XDDRESS Vojh , Lender's Address V(CITY TEL.NO'.' I certify that I have'read this application and state that theCa above information is correct.I agree to comply with all County S{(CENSE NO. CLASS ordinarices and State laws regulating Heating,Ventilating and Air Conditioning,and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE County to enter upon the. above-mentioned roperty for )iii ec 'on _ pose Ignature Date of Permittee " WORKI,RS'COMPI'NSATION DECLARATION CEA366 8C(Z 80) A P P L� C AT�®II�l FOR P C�R fivvli �if I hereby affirm that 1 have a• certificate of consent to self ' insure,or a certificate of Workers'Compensation Insurance,or I a91eQyBRI(y_yC:RIV ID_A�IIi9Cy_AIff3 C®W®GTI®11�11f1��v a certified copy th re fb�f6,S,� 800,Lab.C.) �. �,�j Policy No. �Company' rK�aXf T �L.,/1F'g/��Y 5-5--certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY Certified copy is filed with the county build' g inspection BU ING / rle: n�j' �j FOR APPLICANT TO FILL IN / �4 ����/1/[' ADDRESS Date applicant_. f/� (PRINT OR TYPE ONLY) ��/ ���� LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE COMPENSATION INSURANCE NEARESTNEAR I CROSS ST. �//f� d (This section need not be completed if the work involved ABSORPTION UNIT, BTU p by the permit is for one hundred dollars ($100) or less.) DISTRICT NO. PROCES D BY, U I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM �p� f/ ac permit is issued, i shall not employ any person in any manner �/ O so as to become subject to the Workers' Compensation Laws. BOILER, BTU. . � � APPROVALS DATE INSPECTOR'S SIGNATURE 2llate Applicant COMPRESSOR,BTU r� ROUGH os-S C�'ro N NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEMFINAL 7"� _ �¢•►�--�e Z Exemption, you should become subject to the Workers' e Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION With comply with such provisions or this permit shall be deemed revoked. FURNACE.- FAU LICENSED CONTRACTORS DECLARATION FLOOR: BTU �� I hereby affirm that I am licensed under provisions of Chapter HEATER: SUSPENDED UNIT 9 (commencing with Section 7000)of Division 3 of the Busi- WALL /G� ness and Professions Code, and my license is in full force and effect. License Number Lic.Class Contractor.�Ompt Date J0 El I am exiro!%felficensing requirements as I am a licensed architect or a registered professional engineer Plan check fee 25%of above. acting in my professional capacity (Section 7051, Bus- iness and Professions Code). PERMIT ISSUING FEE$ Lic,or Reg,No. Date TOTAL FEE HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT I hereby affirm that I am exempt from- the Contractor's NAME License Law for the following reason (Section 7031.5, Busi- ness and Professions Cod9): ADDRESS 1, as owner of the property, will do the work and the CITY TEL.NO. structure is .not intended or offered for sale (Section 7044,Business and Professions Code). � -3 7 2 1-3A E] ! OWNER A9. I, as owner of the property, am exclusively contracting ; 0 0 0 0 o D with licensed contractors to construct the project I MAIL /� L�/i.d9 - (Section 7044, Business and Professions Code). ADDRESS L (T�O�.��✓✓��/ CONSTRUCTION LENDING AGENCY CITY TEL.NO. 3Sd�6$S/ - 38. 50 I hereby affirm that there is a construction lending agency I o ^ o j,� o for the performance of the work for which this permit is CONTRACTOR issued(Sec.3097.Civ.C.). Jo �L © 4 L � Lender's Name l ADDRESS D i r Lender's Addressor CITY nos- TEL.NO. I certify that 1 have read this.application and state. that the STA LIC. y LIC above information is correct.I agree to comply with all Count NO. CLASS G ordinances and State laws regulating Heating,Ventilating and , Air Conditioning,and hereby authorize representatives of this I SEE REVERSE FOR EXPLANATORY LANGUAGE County to enter upon the above-mentioned property for inspection pur ses. � � Signature of Permittee Date