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Home My Public Portal About9537 LONGDEN AVE_Mechanical__ Pei WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT s Y•hereby affj�m That I have a certificate of consent to self , insure, or a certificatgof Workers'Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING or a certified copy thereof(Sec. 3800, Ja C. 76A364C CE-818(REV. 10/81) Policy No. /Tel.n 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 �3 tion department: ADDRESS '�L—' (PRINT OR TYPE ONLY) Date &`8�Applicant f C LOCALITY Low NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST COMPENSATION INSURANCE CROSS ST. jam- - (This section need not be completed if the work involved by ABSORPTION UNIT,BTU DISTRICT NO. V PROC BY the permit is for one hundred dollars($100)or less.) AIR HANDLING'UNIT,CFM I certify that in the performance of the work for which this 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 SP OR'S SIGNATURE DateApplicant COMPRESSOR,BTU✓��3�•` m 06 ROUGH on NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL 1 Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATI N with comply with such provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY 'i LICENSED CONTRACTORS DECLARATION FLOOR BTU nA` U od II I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT '(commencing with Section 7000) of Division.3 of the Business WALL and Professions Code,and my license is in full forces�and effect. License Number Lic. Classes w , u Contractor Date ❑ I am exempt under Sec. ) Plan check fee CL CL rI! B.BP.C. for this.reason' PERMIT ISSUING FEE -Date: Signature TOTAL FEE Q OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT ;93423A I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and NAME # 0 0 0 0 0 8 Professions Code): ❑ I, as owner of the property; or my employees with ADDRESS ( 0 a 4�0 0 wages as their,sole compensation,will do the work and CITY TEL. NO. 0 0 0 '4 8,0 050 the structure is not intended or offered for sale(Section 7044, Business and Professions Code). ( 1.07-85 , ❑ J, as owner of the property, am exclusively contracting OWNER with licensed contractors to construct the project (Sec- MAIL /j tion 704,4, Business and Professions Code). ADDRESS JC1JR. CONSTRUCTION LENDING AGENCY CITY�^ TEL. NO. I hereby affirm that there is a construction lending agency'for `l -C the performance of the work for which this permit is issued CONTRACTOR (Sec. 3097, Civ. C.). ADDRESS Lender's Name CITYTEL. NO. 7 Lender's Address STATELIC. �d I certify that I have read this application and state that the LICENSE NO. 5 ZZV CLASS above information is correct. I agree to comply with all County rdinances and State laws relating to building construction, a hereby author' repr •ves of this County to enter up n t abov nt' d p p for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Si nature of Applicant or Agent Date WARKEktOMPENSATION DECLARATION APPLICATION FOR PERMIT inser , a se�rtif cote of Workers'tCom Compensificate of ation eInsurancnt to e, �•° N�'�• p I 7aaae4c HEATING - VENTILATING - AIR CONDITIONING or a cernfted copy thereof(Sec. 3800, Lab. C.) CE-818(REV. 10/81) N Policy No. Company ; Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY a ` Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING tion department. (PADDRESS J 0 n Q h iRINT OR TYPE ONLY) p - Date Applicant LOCALITY NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' NEARECEASES T. f Ytrr<erC9 COMPENSATION INSURANCE (This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO. PROCESSED BY the permit is for one hundred dollars($100)or less.) I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM permit is issued,1 shall not employ any person in any manner so as to becorrie subject to the Workers' �ompensatlon Laws. BOILER,BTU APPROVAL$ DATE IN PE S SIGNAT E k Date -w ApplicanI COMPRESSOR;BTU ROUGH � NOTICE TO APPLICANT: If, after making thisCerti Icate ofAr 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 GRAVITY LICENSED CONTRACTORS DECLARATION FLOOR BTU I hereby affirm that I am licensed under provisions of Chapter 9 I HEATER: SUSPENDED UNIT '(commencing with Section 7000)of Division 3 of the Business WALL and Professions Code,and my license is in full force and effect. I - O License Number Lic. Class , V Contractor Date ❑ I am exempt under Sec. Plan check fee BAP.C. for this reason' 1 Dare: PERMIT ISSUING FEE z�2953,13AA SignatureOWNER- TOTAL FEE BUILDER DECLARATION PLAN CHECK APPLICANT #!o o,c e o 8 I hereby affirm that I am exempt from the Contractor's License _ Law for the following reason (Section.7031.5, Business and NAME :FX -Professions Code): l o o 17.50 I, as owner of the property, or my employees with ADDRESS �3 , �� wages as their sole compensation,will do the work and CITYIt,,r ,p TEL. O. 0 0 0 1 7,5 0 C5 the structure is not'intended or offered for sale(Section 1 t, 0 5 0 4- 88 7044, Business and Professions Code). ❑ 1, as owner of the property,am exclusively contracting OWNER I MAIL with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Busindss and Professions Code). CONSTRUCTION LENDING AGENCY CITY TEL. NO. I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued I CONTRACTOR (Sec. 3097, Civ. C.). ADDRESS Lender's Name CITY TEL. NO. Lender's Address I certifythat I have read this a lication and state that the STATE LIC. pp LICENSE 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 o e mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant VAgent Date