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Home My Public Portal About9574-9576 LOWER AZUSA RD_Mechanical__ WORKERS'CORIPENSATION DLCLARATION CEA 8 8(2 80) APPLICATION FOR PERMIT 1 hereby affirm that I have a certificate of consent to self Insure, or a certificate of Workers'Compensation Insurance,or HEATING-VENTILATING-AIR CONDITIONING „TyLcer fled copy thereof(Sec 3800,Lab C-)— �r dPolicy N ?fCompany RQ-� COUNTY OF LOS ANGE ES/ BUILDING AND SAFETY ElCertified copy is hereby furnished 5?Z.? 2-5 ertified copy is filed with the county building inspeLtion BUI LDI �' d9eartn FOR APPLICANT TO FILL IN , (PRINT OR TYPE ONLY) ADDRE �J !_G Date _ Applicant LOCALITY LRTIrI ATE F EXLMPTIO�WORKERS NO TYPE OF APPLIANCE OR EQUIPMENT FEE C C O COMPENSATION INSURANCE NEAREST } (This section need not be completed if the work involved ABSORPTION UNIT BTU CROSSIST / (,Y� a O by the permit is for one hundred dollars (SI 00) or less) DISTRICT`S P EDB V 1 certify that In tht performance of the work for which this AIR HANDLING UNIT CFM permit is Issued, 1 shall not employ any person In any manner Ile so as to become subject to the Workers Compensation Laws BOILER BTU /- APPROVALS DATE INSPECTOR SeVGINATURE W Date Applicant COMPRESSOR BTU ( it N ROUGH NOTICE TO APPLICANT If after making this Certificate of VENTILATION SYSTEM FINAL 4 ./ - y Z Exemption, you should become subject to the Workers Compensation provisions of the Labor Code you must forth EVAPORATIVE COOLER VAI IDATI N with comply with such provisions or this permit shall be deemed retoked /DFURNACE FAU� /R9r1(I_ - LICENSED CONTRACTORS DECLARATION FLOOR BTU_ 00 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 ness and Professions Code, and my license Is in full force and effect �LLll JJ Lict.nse Nummbbe;R— �/nom- Lie Class 2D ContractoiE�GI— �7�l� Date�/a 0/21 ❑ I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer Plan check fee 25%of above acting in my professional capacity (SeLtion 7051, Bus iness and Professions Code) PERMIT ISSUING FEE$ Lic or Reg No Date TOTAL FEE HOME OWNER BUILDER DLGLARA710N PLAN CHECK APPLICANT I hereby affirm that I am exempt from the Contractor's NAME LILense Law for the following reason (Section 70315 Bust ness and Professions Code) ADDRESS ❑ 1, as owner of the property will do the work and the structure Is not Intended or offered for sale (Section CITY TEL NO 7044 Busmes%and Professions Code) ,�/ ❑ OWNER /G!f/�/�i�/,S # a 0 0 I, as owner of the property am exLlusively contracting %/f�s��—� • • • • with licensed Lontractors to construct the project MAIL 'f (Section 7044, Business and Professions Code) ADDRESS CONSTRUCTION LENDING AGLNCY CI �LS TEL 1 hereby affirm that there is d construction lending agency 9 `/� for the performanct, of the work for sthich this permit Is CONTRTtCTOR .3./�S�L 2 2 07� O� Issued(Sec 3097,Civ C) Lender's Name AODRESC�i L�//_ZIZ�$ }• • 2 7t Lender s Address S AT�/ TEL L�Q1�/J�a/ _ 1 ! certify that 1 have read this application and state that the (�'�'✓rGG 0128 above information is correct l agree to Lomply with all County LICENSE N CLASS ordinances and State laws regulating Heating Ventilating and Air Conditioning,and herLbt authorize represtntatives of this SEE REVERSE rOR EXPLANATORY LANGUAGE County to enter upon the above mentioned property for ispection purposes �le�LQc�. ►/a�lg� Signature of Permittee Date WORKLRS COMPENSATION DLCLARATION CEA 818 (280) APPLICATION FOR PERMIT I herebv affirm that I have i certificate of consent to scif insure or a certificate of Workers Compensation Insurance or HEATING-VENTILATING-AIR CONDITIONING a certified cony thereof(Sec 3800 L�h!� Policy No/ y6116mpany ce COUNTY OF LOS ANGELES T. 42' BUILDING AND SAFETY Certified copy is hereby furnished C�Certified cop) is filed with the count,, building inspection FOR APPLICANT TO FILL IN BUILDING I�j.� dt It �� //�� ADDRESS f !! Date Applicant�y. ___� _ (PRINT OR TYPE ONLY) LOCALITY CLRTIFICATEOf EXEMPTION FROM WORKERS' NO TYPE OF APPLIANCE OR EQUIPMENT FEE COMPENSATION INSURANCE NEAREST CROSS STS ti (This section need not be completed if the work involved ABSORPTION UNIT BTU O by the permit is for one hundred dollars (5100) or less) DISTRICT NO fROCESSE By 0 I certify that in the performance of the work for which this AIR HANDLING UNIT CFM tr permit is issued i shall not employ any person in an) manner 0 so as to bLLOMe subject to the Workers Compensation Laws BOILER BTU APPROVALS DATE INSPECTOR S SIGNATURE W Date Applicant r COMPRESSOR BTU ROUGH r. N NOTICE TO APPLICANT It after making this Certificate of VENTILATION SYSTEM � , Z Exemption, you should become subject to the Workers I FINAL Compensation pro,,tsions 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 ' LiCE"NSLDCONTRACTORSDECLARATION FLOOR BTU I hereby affirm that i am licensed under provisions of Chapter HEATER SUSPENDED UNIT p 2 yz 9 (commencing with Section 7000)of Division 3 of the Bust WALL ness and Professions Code and my license is to full force and / effect �j y / License Numbcrgm /� Lic Class ®� Date Contractor i am exempt from the licensing 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 FEE / iness and Professions Code) PERMIT ISSUING V .?-(3 Lie or Reg No Date TOTAL FEE %0 ! (o HOME OWNER BUILDER DECLARATION PLAN CHECK APPLICANT ) hereby affirm that I am exempt from the Contractors NAME License La%% for the following reason (Section 7031 5 Bust nesS Ind Professions Code) ADDRESS z,0 9 9 1 A 1, as Dinner of the ro ert) will do the work and the I CITY p p TEL NO # • • • • • structure is not intended or offered for sale (Section + i 7044 Business and Professions Code)❑ 2+• - 2050 OWNER �L_�T_ y � i, as owner of the property, am exclusively contracting ��"�f�r✓G with licensed contractors to construct the proleet MAIL /J _f�'� _I� �• • • 2 0 5 0 C (Section 7044 Business and Professions Code) ADDRESS CONSTRUCTION LENDING AGENCY CITY TEL N003 637 6195 105.04-84 i hereby affirm that there is a construction lending agency for the performance of the work for which this permit is CONTRACTOR 9, issued(Sec 3097 Civ C) Lender's Name ADDRESS Lender's Address CITY TEL NO 7f3 I/ I certify that i have read this application and state that the STATEd LIC 1 abo,,e information Is correct I agree to comply%%ith all County LICENSE NO 7�/ 7 CLASS ordinances Ind State laws regulating Heating, Ventilating and • Air Conditioning, and hercb% authorize representatt,,es of this SEE REVERSE rOR EXPLANATORY LANGUAGE Count) to enter upon the above mentioned property for iiisn�purposes .7 Signature of Per n ttee Date