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Home My Public Portal About9638-9640 LONGDEN AVE_Mechanical__ WORKERS'CbMPENSA"'fION DECLARATION APPLICATION FOR PERMIT y affit m that I have a certificate R consent to self insure, or a certificate of Workers'Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING or a'cerfifiecL cop �thereo (Sec. 3800�Lab�� 76A364C [G0 da. aJ `ti J�T�`- CE-818(REV. 10%81) Policy a fmpany Certified copy is hereby furnishe ' COUNTY OF LOS ANGELES BUILDING AND SAFETY aCertified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING tion de artme t. ADDRESS �J Date Applicant �7's `'�J (PRINT OR TYPE ONLY) LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE ✓ `- NEAREST COMPENSATION INSURANCE CROSS ST. (This section need not be completed if the work involved by ABSORPTION UNIT,BTU DISTRICT NO. PROCESSE Y the permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM �j I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws. BOILER,BTU / APPROVALS DATEECTOR'S SIGNATURE Date Applicant COMPRESSOR,BTU 7` ROUGH -47 � NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATI N with comply with such provisions or this permit shall be deemed revoked. FURNACE: FAU Gg�4V�T LICENSED CONTRACTORS DECLARATION FLOOR Q I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT '(commencing with Section 7000) of Division 3 of the Business - WALL and Professions Code,and m license is in full force and effect. y 0& z,rl` ' License�lum a ��O Lic. Clas,,sQ , to ad 7 7 4 A ContractoW_-��o_ �/b-r'V Date " # 0,00008 tJ !� 1 am exempt under Sec. � Plan check fee :1 0 o 8 8,0 0 B.&P.C. for this reason Date. PERMIT ISSUING FEE$ 0 i 088,00= Signature TOTAL FEE OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT o 8,2 7 8 7 I hefeby 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 TEL.NO. 7044, Business and Professions Code). OWNER ❑ I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec- MAIL ADDRESS tion 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY CIT TEL. Ne,-4f2, I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued CONTRACTOR (Sec. 3097, Civ. C.). ADDRESS - Lender's Name Ale- 14�1 CITY TEL. NO�� Lender's Address STATE LIC: I certify that I have read this application and state that the LICENSE NO. 2 CLASS cZG 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 th bove-m-m ntioned property for inspection pup s s. SEE REVERSE TOR EXPLANATORY LANGUAGE Signature of Applicant or Agent Date � rWORKERS'6OMPEN3A-TIOpJ DECLARATION .ffri'rr that I have a certificate of consent to self APPLICATION FOR PERMIT q ihm"07ft,�VF a certificate of Workers'Compensation Insurance,y HEATING - VENTILATING - AIR CONDITIONING or a certified copy thereof'(Sec. 18Lab. C. 76A364C _ CE-818(REV. 10/81) Policy��Cn 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 deportment (PRINT OR TYPE ONLY) ADDRESS koh Date pplican - Awou LOCALITY NO. TYPE OF APPLIANCE OR EQUIPMENT FEE _ / `�✓ CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST ,7' COMPENSATION INSURANCE CROSS ST. - /17 �� a '(This section need not be completed if the work involved by ABSORPTION UNIT,BTU DISTRICT NO. PROCESSE BY the permit is for one hundred dollars($100)or less.) I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM v permit is issued, I shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws. BOILER,BTU APPROVALS DATE I OR'S SIGNATURE Date Applicant COMPRESSOR, BTU 7 �c/� 00 ROUGH NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION with.comply with such provisions or this permit shall be deemed revoked. FURNACE: FAU G `�T LICENSED CONTRACTORS DECLARATION FLOOR BTU V(J I hereby affirm that I am licensed under provisions of Chapter 9HEATER: SUSPENDED WALL UNIT '(commencing with Section 7000)of Division 3 of the Business � and Professions Code, �� and m/y license is in full force and effect. 37. License Number- / eLic. Classes Contractor Date ❑ I am exempt under Sec. 2 Plan check fee ']']g W B.BP.C. for this reason' # o,0 0 0, Date: PERMIT ISSUING FEE$ 99 Signature TOTAL FEE -1 "e'a 5.9 2 5 OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT o,a o 5 9.2 5,5 I hereby affirm that I am exempt from the Contractor's License , O 2 7,�8 7 Law for the following reason (Section 7031.5, Business'and NAME Professions Code): o ❑ I, as owner of the property, or my employees with ADDRESS wages as their sole compensation,will do the work and CITY TEL. NO. the structure is not intended or offered for sale(Section 7044, Business and Professions Code). OWNER , ❑ I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec- MAIL tion 7044, Business and Professions Code). ADDRESS CONSTRUCTION LENDING AGENCY CITY TEL. NO. ��„ 111/ � I hereby affirm that*there is a construction lending agency for10 the performance of the work for which this permit is issued CONTRACTOR (Sec. 3097, Civ. C.). ADDRE Lender's Name CITY7'i,--- y�i TEL. N ��" Lender's Address STATE /,,� LIC. v I certify that I have read this application and state that the LICENSE NO. d 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 u n the above a toned property for inspection.p rposes. -SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of AppJicant or Agent Date