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Home My Public Portal About9665 LONGDEN AVE_Mechanical__ WORKER .�COMREINSATION DECLARATION APPLICATION k p p L I C/k T I O N FOR PERMIT ER)AA I T -91 F�rek�ji affirm thak I have a certificate of consent to self Mr r /`1 1 r „ .1/■ In rcer�IN certificale (Sec838 Oomp nssation Insurance, 76A364C HEATING - VENTILATING - AIR CONDITIONING +i 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. (PRINT OR TYPE ONLY) ADDRESS S 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. PROCEsJb BY the permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM I certify that in the performance of the work-for which this permit is issued, I shall not employ any person in any manner so as To become subject to the Workers'Compensation Laws. BOILER,BTU APPROVALS DATE I ECTCIPA SIG URE (� A � COMPRESSOR,BTU Q ROUGH Date • pplicant NOTICOF TO A PLICANT: If, after a ing t is Certificate of VENTILATION SYSTEM ' p FINAL Exemption, you should becom subject to the- Workers' Compensation provisions of the bar Code, you must forth- EVAPORATIVE COOLER VALIDATION with comply with such provisions or this permit shall be deemed revoked. FURNACE: FAU G VITY LICENSED CONTRACTORS DECLARATION FLOOR BTU ��- •e V� 1 hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED f UNIT '(commencing with Section 7000)of Division 3 of the Business WALL 0. and Professions Code,and my license is in full force and effect. O. License Number Lic. Class , V 09 Contractor Date ❑ LU I am exempt under Sec. Iw Plan check feeIL B.BP.C. for this reason' ,1 PERMIT ISSUING FEE$ Cj Date: TOTAL FEE Signature _ OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT �b 3 a 8 A I hereby affirm that I am exempt from the Contractor's License , # e o 0 0 0 8 Law for the following reason (Section 7031.5, Business and NAME Professions Code): I a o30,50 WAI, as owner of the property, or my employees with ADDRESS wages as their sole compensation,will do the work and CITY TEL. NO. a a a 3 a 5 0 r�i the structure is not intended or offered.for sale(Section 7044, Business and Professions Code). OWNER ' c 1, 0 8 8 7 ❑ I, as owner of the property,am exclusively contracting MAIL with licensed contractors to construct the project (Sec- ADDRESS L tion 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY CITY TEL. NO. 7CxD S I hereby affirm that there is.a construction.lending agency for Poo performance of the work for which this permit is issued CONTRACTOR (Sec. 3097, Civ. C.). ADDRESS Lender's Name CITY TEL. NO. _ Lender's Address STATE LIC. I certify that I have read this application and state that the LICENSE NO. CLASS labove 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 entioned property for inspWctionurposes, SEE REVERSE FOR EXPLANATORY LANGUAGE ature ofApplicant or Agent ION WORKER'S I vii a certificate of consent to 7BA346DPW9189 APPLICATION FOR PERMIT LIME GREEN, 78A384C I hereby affirm that I have a certificate of consent to self insure, gr a certificate of Worker's Compensation Insurance, or a certified l HEATING-VENTILATING-AIR CONDITIONING copy thereof(Sec.3800_ Lab..C.) Policy N ` 7D�Co�pany�Al& COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV. E Certified copy is hereby furnished: Certified copy is filed with the county b 'Ids Inspection FOR APPLICANT TO FILL IN AUILDINGDDRESS` Id(� hf.�•�/ e department. h g 1 (PRINT OR TYPE ONLY) WJ `'r- -/ Applicant LOCALITY Date S NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FRO ORKERS' NEAREST —i-,A �V CROSS ST. J,%_% k3 COMPENSATION INSURANCE ABSORPTION UNIT,BTU (This section need-not be completed if the work Involved by the ASSESSOR MAP BOOK PAGE PARCEL permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO. PROCESSED BY I certify that in the performance of the work for which this permit is Issued, I shall not employ any person in any manner so as to BOILER,BTU become subject to the.Workers'Compensation Laws. (/Q COMPRESSOR,BTU APPROVAL6 DATE INSPECTOR'S SIGNATURE Data Applicant VENTILATION SYSTEM NOTICE TO APPLICANT: If, after making this Certificate of ROUGH Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER provisions of the Labor Code,you must forthwith comply with such FINAL provisions or this permit shall be deemed revoked. i FURNACE: FAUGRAVITY LICENSED CONTRACTORS DECLARATION FLOOR BTU 1191C01112 �S VALIDATION I hereby affirm that I am licensed under provisions of Chapter 9SUSPENDED UNIT (commencing with Section 7000)of Division 3 of the Business and HEATER: ' WALL Professions Code,and my license is in full force and effect. 15,A L License Number ' r Lic.Class t T..0 1-`m J4r3GE,.1L , ;' m �3 C Contractor Date If- �i4C•I a ❑ Plan check fee I am exemp under Sec. 13 3 L 0 4 j C B.BP.C.for this reason PERMIT ISSUING FEE$ H S18 I ITEMt: C Date: TOTAL FEE OAA.0 177® G T HL � �0 m 0 d Signature U OWNER-BUILDER DECLARATION PLAN'CHECK APPLICANT CHECK 80.40 Z I hereby'-affirm that I am exempt from.the Contractor's License Law NAME ' CHANGE for the following reason(Section 7031.5, Business and Professions i Code): ADDRESS!, ❑ 1, as owner of the'property, or my employees with wages � _ � ur 5/73as their sole compensation, will do the work and the CITY I TEL.NO. structure is not intended or offered for sale(Section 7044, j 1i itr7s � v7�;�+2 Business and Professions Code). OWNER / 1 �1 = ❑ I, as owner of the property, am exclusively contracting L N MAIL with licensed contractors to construct the project (Sec- ADDRESS, f,6 4,y- tion crtion 7044,Business and Professions Code). i CONSTRUCTION LENDING AGENCY CITY V5 ek r'rY TEL.NO..X T 7 y 0 3 s, I hereby affirm that there is a construction lending agency for i / the performance of the work for which this permit Is Issued CONTRACifOR • L (Sec.3097,Civ.C.). ADDRESS c7 y2 Lender's Name CITY , UN,�d�l� TEL.NO� Lender's Address certify that I have read this application and state that the above LICENSE NO. 6 49 7 CLASS Information is correct..i agree to comply with all County ordinances and State laws relating to building construction,and hereby authorise , representatives of this County to enter upon the above-mentioned :;A per yfoinspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE TURE OF' OR.AOENT DATE= 1 ,