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Home My Public Portal About9600 LOWER AZUSA RD_Mechanical__ WORKERS COMPENSATION DECLARATION -76 364C ` I hereby affirm that I have a certificate of conxent to self CE 11"U2 60) A 1��,,,,��M�CAT I O N FOR PERMIT insure od c ceritheree of Workers Compensation Insurance or HER�141'drLa-VENTILATING-AIR CONDITIONING 6 C$ a certified copy thereof(Sec 3800 Lab C) Policy No Company Certified copy is hereby furnished COUNTY OF LOS ANGELES BUILDING AND SAFETY Certified copy is filed with the county building inspection BUILDING department FOR APPLICANT TO FILL IN q ILDIN91A / — L Date Applicant (PRINT OR TYPE ONLY) CERTIFICATE OF EXEMPTION FROM WORKERS NO TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY Vrb C COMPENSATION INSURANCE NEAREST 1 _ /� �+ SOW (This section need not be completed if the work involved ABSORPTION UNIT BTU CROSS ST rQyYr<, L� L T� Il O by the permit 1S for one hundred dollars ($100) or less) DISTRICT NO PROCESSED BY (� I certify that in the performance of the work for which this AIR HANDLING UNIT CFM O permit is issued I shalt not employ any person m ner so as to become subject to the Wo� BOILER BTU 0 ..�. APPROVALS DATE INSPECTOR SSIGNATURE Date.--�3Applicant !QttM. COMPRESSOR BTU D ROUGH y NOTICE TO APPLICANT If after making this Certificate of VENTILA-LION SYSTEM Z Exemption you should become subject to the Workers FINAJ Compensation provisions of the Labor Code you must forth with comply with such provisions or this permit shall be EVAPORATIVE COOLER VALIDATION deemed revoked FURNACE FAU GRAVITY— LICENSED CONTRACTORS DECLARATION RAVITY LICENSEDCONTRACTORSDECLARATION FLOOR - BTU I hereby affirm that I am licensed under provisions of Chapter HEATER SUSPENDED UNIT 9 (commencing with Section 7000)of Division 3 of the Busi WALL ness and Professions Code and my license is in full force and J p- O- 0 (V op effect .� ®I�� /�� License NumberP� *f Iff Lic Class C � a Contractor *JV /1%te >I( P"E-3 ZIEl I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer Plan check fee 15%of above acting in my professional capacity (Section 7051 Bus mess and Professions Code) PERMIT ISSUING FEE$ Lic or Reg No Date TOTAL FEE `HOME OWNER BUILDER DECLARATION PLAN CHECK APPLICANT I hereby affirm that I am exempt from the Contractors NAME License Law for the following reason (Section 7031 5 Busi o ness and Professions Code) ADDRESS 22'6 18 A I as owner of the property will do the work and the CITY TEL NO # • • • •r• 8 structure is not intended or offered for sale (Section 1 7044 Business and Professions Code) nn q c - 2750 QOWNER 0 K 2 • I as owner of the property, am exclusively contracting V 0 with licensed contractors to construct the project MAIL •'• • 2 7 5 Q Q(Section 7044 Business and Professions Code) ADDRESS CONSTRUCTION LENDING AGENCY CITY r TEL NO 0 6 0 8—8 3 I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is ONTRACTOR �— issued(Sec X097 Civ C) Lender s Name ADDRESS 2- L� v Lender s Address CIT pm 0` � TE4 NO I certify that I have read this application and state that the above information is correct 1 agree to comply with all County LICENSE NO CLASS ordinances and State laws regulating Heating Ventilating and " Air Conditioning and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE P County to enteryy��ppn t above mentioned property for ps�c n purpo esg Slgnature of Permittee Date _ , WORKER S COMPENSATION DECLARATION 7626334 C PW 9/69 APPLICATION FOR PERMIT LAME GREEN I h�eby S)firm that I have a certificate of consent to self Insure or a ert.fioate of Worker s Compensation Insurance or a certified HEATING-VENTILATING-AIR CONDITIONING copy thereot(Sec 3600 Lab C) `0 Policy No Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV ElCertified copy Is hereby furnished ❑ Certified copy is filed with the county building Inspection FOR APPLICANT TO FILL IN BUILDING department , (PRINT OR TYPE ONLY) ADDRESS Date Applicant I I LOCALITY NO TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS NEAREST COMPENSATION INSURANCEO O� BO CROSS ST ABSORPTION UNIT BTU (This section need not be completed If the work Involved by the I MAP BOOK PAGE PARCEL a permit is for one hundred dollars($100)or less) AIR HANDLING UNIT CFM DISTRICT NO PROCESSED BY'" I certify that in the performance of the work for which this permit Is Issued 1 shall not employ any person in any manner so as to I BOILER BTU become subject to the Workers Compensation Laws ZS 91 � COMPRESSOR BTU 00 Date Applicant / VENTILATION SYSTEM APPROVALS DATE INSPECTOR 8 SIGNATURE NOTICE TO APPLICANT If after making this Certificate of ROUGH ,0 —Z y Exemption you should become subject to the Workers Compensation EVAPORATIVE COOLER —/j provisions of the Labor Code you must forthwith comply with such FINAL /(p provisions or this permit shall be deemed revoked FURNACE FAU GRAVITY LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATION I hereby affirm that I am licensed under provisions of Chapter 9 HEATER SUSPENDED—UNIT— (commencing USPENDED UNIT(commencing with Section 7000)of Division 3 of the Business and WALL Professions Code andmylicense is in full force and effect License Number 5'9 0109 Lic Class v`® i Contractor CX7Lq * *,ck Date as 9 F1Plan check fee U I am exempt under Sac loc 8 f4P C for this reason PERMIT ISSUING FEE$ O H 2 -- D TOTAL FEE mp W S_igna_ture CL OWNER BUILDER DECLARATION` PLAN CHECK APPLICANT Z I hereby affirm that I am exempt from the Contractors License Law NAME , u for the following reason(Section 7031 5 Business and Professions Code) ADDRESS Ai 5rT a ` I as owner of the property or my employees with wages �s as their sole compensation will do the work and the CITY TEL NO 3307 37.00 structure is not Intended or offered for sale(Section 7044 ITEMS Business and Professions Code) OWNER Coins ❑ I as owner of the property am exclusively contracting �q- TOTAL 37.00 with licensed contractors to construct the project (Sec ADDRESS 1-0Lo Cr LC�t� CHECK 37.011 tion 7044 Business and Professions Code) ,s CONSTRUCTION LENDING AGENCY CITY,"E,m, G 0-4 TEL NO CHANE .I1 I hereby affirm that there is a construction lending agency for CONTRACTOR Fre /) the performance of the work for which this permit fa issued f rn - (Sec 3097 Civ C) t ► t 0 4 Lender s Name ADDRESS 0� , IUe- Ov 0000y—OM 1{ 2/26/91 CITY Mon TEL N g1�3t>3-� Z 58000 1 AM 10:0 3 Lender s Address I certify that I have read this application and state that the above LICENSE NO ,j CLASS C,2- information is correct 1 agree to comply with all County ordinances and State laws relating to building construction and hereby authorize A representatives of this County to enter upon the above mentioned property for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE SIGNATURE OF APPLICANT OR AGENT DATE i WORKER I haveCOMPENSATION ate of consent to 76A3 aDPW9l89 APPLICATION FOR PERMIT �� EGREEN I hereby affirm ttjpt 1 have a certificate of consent to self insure 78A364C or a cef+fficate of Worker a Compensation Insurance or a certified HEATING-VENTILATING AIR CONDITIONING I I copy thereof(Sec 3800 Lab C) u Policy No Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV Certified copy is hereby furnished ❑ Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN ADDRESS UILDING Q(� 4� 4 department (PRINT OR TYPE ONLY) LOCALITY &Y city t,L� Date Applicant NO TYPE OF APPLIANCE OR EQUIPMENT FEE �l rLC CERTIFICATE OF EXEMPTION FROM WORKERS NEAREST ? COMPENSATION INSURANCE CROSS ST aPevr rC 4 ABSORPTION UNIT BTU ASSESSOR (This section need not be completed if the work Involved by the MAP BOOK PAGE PARCEL permit is for one hundred dollars($100)or less) AIR HANDLING UNIT CFM DISTRICT NO PROCESSED BY I certify that In the performance of the work for which this permit is issued I shall not employ any person in any manner so as to BOILER BTU- become subject to the Workers Compensation Laws y� !/a Date--fl 9S Applicant MApK j+�u k COMPRESSOR BTU D APPROVALS t DATE INSPECTOR S SIGNATURE VENTILATION SYSTEM NOTICE TO APPLICANT If after making this Certificate of ROUGH Exemption you should become subject to the Workers Compensation EVAPORATIVE COOLER S FINAL provisions of the Labor Code you must forthwith comply with such v 00117-11-16- provisions or this permit shall be deemed revoked FURNACE FAU GRAVITY LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATION 1 hereby affirm that I am licensed under provisions of Chapter 9 HEATER SUSPENDED UNIT (commencing with Section 7000)of Division 3 of the Business and WALL Professions Code and my license is in full force and effect License Number 6 3 �� Lic ClassUJ n*r Contractor FU r—DRE —Date 7 S ► D. ElPian check fee iT a I am exempt under Sec Cr. / B&P C for this reason PERMIT ISSUING FEE$ y O s 0303 7 i� ate TOTAL FEE B'� ��W Signature 1 ITOS N OWNER BUILDER DECLARATION PLAN CHECK APPLICANT TOTAL 75. 003 1 hereby affirm that I am exempt from the Contractors License Law NAME /LOT �� 010. ME� �} n V for the following reason(Section 7031 5 Business and Professions / �//' EST ► Code) ADDRESS `� S� , GHAhl�E ,GO ❑ I as owner of the property or my employees with wage as their sole compensation will do the work and tis CITY Inp�0 C TEL N structure is not intended or offered for sale(Section 704 s nrt nn i t a Business and Professions Code) OWNER 0000-0001 7/ 6/99 ❑ 1 as owner of the property am exclusively contracts MAIL 1212 1 FM 4'1'3 with licensed contractors to construct the project (Se ADDRESS sG.Odv US)l R0 _ tion 7044 Business and Professions Code) Tr ng_F CONSTRUCTION LENDING AGENCY CITY TEL NO I hereby affirm that there Is a construction lending agency for ONTRACTOR the performance of the work for which this permit Is Issued JQ - (Sec 3097 Civ C) X Lender s Name ADDRESS JJ'' rjj �]q��(.ryn� CD/+p7T f+�eT) CITY /l,c TEEL71NO (G J)q) / n Lenders Address STATE LIC I certify that I have read this application and state that the above LICENSE NO CLASS nformation ss correct I agree to comply with all County ordinances _ r nd State laws relating to building construction and hereby authonze epresentatives of this County to enter upon the above mentioned property fr spection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE d 9s , SIGNATURE APPLICANTO rAGENT DATE