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HomeMy Public PortalAbout10141 LYNROSE ST_Mechanical__ WORKERS' CI haT cvrti DECLARATION to self n P�U CA77 ®n n F®R PERMIT I hereby affirm that I �aWo keis',Comtpe&at on Insurance, ( f �( insure, ora ertificatgg of VC 76A364C HEATING = VENTILATING - AIR,CONDITIORIING or a certifie c_o th@reoff (Sec .384 Lab-,C Tom• a Policy NoJ �d 20-0046 DPW 9%88 Certified copy ls_hereby furnished ' COUNTY OF LOS ANGELES BUILDING AND SAFETY Certified copy Is filed with the county buildirg inspec- 'tion' speo- FOR APPLICANT TO FILL IN BUILDING tion department'. (PRINT OR TYPE ONLY) ADDRESS Date" D Applican LOCALITY TLC�71OG` /,— • r s '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 P SED BY the permit is for one hundred dollars'($100) or less.) = /� ot i,certify,that In%the-performance of the work for w h this AIR HANDLING UNIT, CFM '1permit Is Issued, Ishall not employ any person nyb h ner ` so as to become subject to the Workers' pensatlon'Laws BOILER, BTU APPROVALS DATE INSP TOR'S SIGNATURE Date Appllc���� COMPRESSOR, BTU D ROUGH NOTICE TO APPLICANT--If,',after* making'this,Certificate'of•,- VENTILATION SYSTEM FINAL Exemption, you�uld become subject, to the Workers' Compensatiorf"provisions of the'L'abor Code, you must forth- EVAPORATIVE COOLER VALIDATION with comp yl with such,provlsions or-this permit shall,be deem- ed.rt=voked FURNACE FAU GRAVITY / LICENSED CONTRACTORS'DECLARATION FLOOR' BTU / I hereby affirm that I am licensed under provisidns of Chapter 9 SUSPENDED UNIT • (commencing withSection 7000)of Division-3 of,the BusinesHEATER WALLs ' and Professions Code,and my license Is In full force and effect yg3P70 C ,aCL License Number' /} Llc. Class O y, Contractor � �/� � + 'nate D V `, '❑, aC I am exempt,under Sec Plan check fee v W e, &&P C for.this reason PERMIT ISSUING FEE $ CL ' Date � ` Signature TOTAL FEE - ° OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT i I hereby affirm that I,'am exempt from'the Contractor's License D r Law for the following reason (Section 7031 5, Business arid NAME Professions Code) ❑ j, as owner of the property, or,my employees with ADDRESS~ a' A wages as their sole compensation,will do the work and { I DCCT°v ' the structure is not intended or-offered for sale Se Ion" * CITY••-- — TEL NO '1 77. { 7044, Business and Professions Code) ( `.• t J 1��"1 N ^❑ j, as owner of,The.property, OWNER-. /� p p y, am exclusi ,conirachng vv,/ - � '- - t, t1 aITEP1S with licensed contractors to constr a project (Sec- MAIL tion 7044, Business and Profes ns Code) ADDRESS - ID� �OS {,{T �'� 00 CONSTRUCTION LE G AGENCY CITY �"' �yy7�G�G/ TEL NO 4 ,f�6 9 CHECK -67.00 I hereby affirm that there 11-d construction lending agency for the performance of Th ork for which this permit Is issued CONTRACTOR {/� CHANGE °00 (Sec 3097, Clv C �� �� 7�'Oi Lender's N e ADDRESS - n� /ty. e•. CITY �C / TEL NO �/���•� . .~ —l.1Ul'�• 1/ 3196 Lend is Address -7 TE LIC I certify that I have read this application and state that the LICENSE NO CLASS C pZCJ 8105 1 AN10:51 above information is correct I agree to comply with ail County I ordinances'and State jaws relating to building construction, _ and hereby authorize representatives of this County to enter upon move-men oned prop rty,for Inspection purposes - 1 �/�,�� / n�_ �/l , SEE,REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent Date 4 ©s WORKERS'COMPENSATION'DECLARATION CEA 8 18 (2.80) A P P UCAT 8.ON Ir O R P FABS dVU T I hereby affi,m that Ihave a certificate of,consent,to self, Insure, or a certificate of^Workers'Compensation Insurance,or HEATING-VENTILATING-AIR COW®IYIOWIWCv a certified copy thereof(Sec 3800,Lab C) - Policy No r Company 0 Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY Certified'copy is filed with'the county building inspection FOR APPLICANT TO FILL IN' BUILDING department /J'1/�, Date Applicant (PRINT OR TYPE ONLY) ADDRESS i/ 41 q/!/QB�, LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE'OR EO'UfPMENT FEE P" /�/l' / COMPENSATION INSURANCE NEAREST fl (This section need not.•be completed if the work involved ABSOflPTION UNIT, BTU CROSS ST • 'by the permit is for one.hun ed dollars-( 100) or less.) , DISTRICT NO PROCESSED BY O ti A certify that,m the performance the.work for which this AIR HANDLING UNIT,CFM permit is issued. I shall 'not mploy a y arson imany manner_ / ���,' 0 �p K O 0 so,as to ieco ne subject to Work rs' ompensation Laws ( BOILER, BTU / i F APPROVALS DATE INSPECTORS SIGNATURE- , W Date �3 Applicant— COMPRESSOR,BTU' C ROUGH •NOTICE TO APPLICANT'. If,,after making this Certificate of " VENTIILATION SYSTEM Z Exemption, you should become subject to the Workers' FINAL Compensation provisions of the Labor Code, you must,forth- E COOLER with comply with such EVAPORATIVE provisions of this permit shall be VALIDATION deemed revoked FURNACE FAU GRAVITY— LICENSED RAVITY LICENSED CONTRACTORS DECLARATION 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 �. effect. Incense Number Lic.Class Contractor Date 0- 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- iness-and Professions Code), PERMIT ISSUING FEE$ 49V Lic or Reg.No Date TOTAL FEE ' HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT I hereby affirm that 1,amexempt from-the Contractor's NAME License Law for the following reason (Section 7031.5, Busi- ness and Professions Code) ADDRESS T 1, as owner of the property, will do the-work and the CITY TEL. NO. :2O 71 A structure is not intended or' dffered for sale (Section 7044, Business and Professions,Code) -Q jo�0`0 0 0- n - ` ' OWNER .. - - .#( - 8 I, as ower of the property, am exclusively contracting' with licensed contractors to construct the . project MAIL. 2 -e:-'2 7 O O (Section 7044, Business and Professions Code). ADDRESS CONSTRUCTION LENDING AGENCY CITY TEL NO :o)e 0 2 7 O O v I hereby affirm that there is a-construction lending agency for the performance of'the work for_which this permit is-- CONTRACTOR 150 issued(Sec. 3097,Civ-C.). — Lender's Name ADDRESS Lender's Address CITY TEL.NO I certify that I have read this application and state that the STATE LIC. above information is correct I agree to comply with all County- LICENSE NO CLASS ordir_, 'a and State laws regulating Heating, Ventilating and -Air Condit ning, and,hereby authorize representatives of this SEE'REVERSE FOR EXPLANATORY LANGUAGE Cc unty -to enter upon the above-menti(ned properly for u,lection r ses. _ ; Signature of Permittee Dae -