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Home My Public Portal About10733 LYNROSE ST_Mechanical__ WORKER'S I COMPENSATION ate of consent to 76A364C /89 APPLICATION FOR PERMIT UIGREEN I hereby.ailTrro that I hrwe a certificate of consent to self insure, �7 or a'certificate of Worker's Compensation Insurance,or a certified HEATING-VENTILATING-AIR CONDITIONING 7u� copy thereof(Sec.3800 L Policy N 4ry–ol_ Company 27• zeoz-e COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV. ❑ Certified copy Is hereby furnished. /–/– /f.3 �- Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN BUILDING PC d -artme t. r.,/QQ 9 p (PRINT OR TYPE ONLY) ADDRESS 1.� Date Applicant r `�-�u LOCALITY ,//�� NO. TYPE OF APPLIANCE OR EQUIPMENT FEE NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' *14 Co CROSS ST. COMPENSATION INSURANCE 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($700)or less.) AIR HANDLING UNIT CFM DISTRICT NO. PROCESSED BY I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to BOILER.BTU become subject to the Workers'Compensation Laws. 6 �2 2-5 Q� COMPRESSOR,BTU �J APPROVALS DATE INSPECTOR'S SIGNATURE. Date Applicant VENTILATION SYSTEM NOTICE TO APPLICANT: If, after making this Certificate of ROUGH Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER provisions of the Labor Code,you must forthwith comply with such FINAL provisions or this permit shall be deemed revoked. p FURNACE: FAU X GRAVITY LICENSED CONTRACTORS DECLARATION / FLOOR BTU VALIDATION I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED—UNIT— (commencing USPENDED UNIT(commencing with Section 7000)of Division 3 of the Business and HEATER: WALL Professions Code,and my license is in full force and effect. S License Number 1"� Lic.Class— =0 7 C Contractor C_ Date (; ❑ I am exempt under Sec. Platt Check fee e a B.&P.C.for this reason PERMIT ISSUING FEE$ 7 O a. 7� C Date: TOTAL FEE -�7 V � 8 Signature OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT 74– &V2A 1 hereby affirm that I am exempt from the Contractor's License Law NAME 000. v1 for the following reason(Section 7031.5, Business and Professions Code): ADDRESS I, as owner of the property, or my employees with wages as their sole compensation, will do the work and the CITY TEL.NO. structure is not intended or offered for sale(Section 7044, Business and Professions Code). OWNERUL;T ❑ 1, as owner of the property, am exclusively contracting MAIL Ipv p with licensed contractors to construct the project (Sec- ADDRESS16 (r tion 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY CI TEL.NO.57 7 413 1hereby affirm that there is a construction lending agency for CONTRACTOR the performance of the work for which this permit Is issued sy Q (Sec.3097,Civ.C.). ADDRESS Lender's Name CITYTEL.NO& 7q Lender's Address W�J I certify that I have read this application and state that the above LICENSE NO. -/ 4- 141 LIC. �' c 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-mentioned pr �erty for ins action urposes. SEE REVERSE FOR EXPLANATORY LANGUAGE AM E SIGNATURE,f AP CANT OR AGENT O WORKERS'COMPENSATION DECLARATION CEA38648C12 80) A I�I�p Imo" q, T�®f�.11 Fi O R fid E R I1L1 T I hereby affirm that I have a' certificate of consent to self I I("If-I!= �s 6=i �1 II- If�S I!-LS Ifs IVU insure,or a certificate of Workers'Compensation Insurance,or j HEATING-VENT ILATING-AlR CONDITIONING a er fied co Y h r (Sec.3800,Lab C.), N3J 3 rP� .J.- �/ Po Icy o. Company ❑ Certified copy is hereby furnished. COUNTY OF LOS ANGELES T., i BUILDING AND SAFETY 1 �Certified copy is filed with the co mtv uildi inspection BUILDING + dygart FOR APPLICANT TO FILL IN ADDRESS lb73 C � Qbs� Date '� Applicant (PRINT OR TYPE ONLY) LOCALITY CERTIFICATE OF EXEMP ON FROM RKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE COMPENSATIO INSURANCE NEAREST (This section need not be completed if the work involved ABSORPTION UNIT,BTU CROSS ST. 0 by the permit is for one hundred dollars ($100) or less.) DISTRICT NO. PROCESS By _ U I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM1=permit is issued, I shall not employ any person in any manner t-.L/) O so as to become subject to the Workers'Compensation Laws. i BOILER,BTU ' 01, 0C) Pe 1-- APPROVALS DATE INSPECTOR'S SIGNATURE W Date Applicant COMPRESSOR,BTU ROUGH N NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL ro-Z-of qr Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code,you must forth- EVAPORATIVE COOLER VALIDATION with comply with such provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY LICENSED CONTRACTORS DECLARATION FLOOR: BTU I hereby affirm that I am licensed under provisions of Chapter HEATER: SUSPENDED UNIT 9 (commencing with Section 7000)of Division 3 of the Busi- WALL ness and Professions Code, and my license is in full force and effect. License Number-M-5 107- Lic.Class QC `S3 Contracto I Date 7— ❑ I am exempt om t licensing requirements as I an a licensed architect registered professional engineer Plan check fee 25%of above. acting in my professional capacity (Section 7051,•Bus- iness and Professions Code). ! PERMIT ISSUING FEE$ Lic,or Reg.No. Date TOTAL FEE HOME OWNER-BUILDER DECLARATION i PLAN CHECK APPLICANT � -/ I hereby affirm that I am exempt from- the Contractor's NAME CALI FD"l A 4200 /V / en License Law for the following reason (Section 7031.5, Busi- 9-0 6 8,b A ness and Professions Code): ADDRESSe804 LJs 7c-)Ays ❑ I, as owner of the property, will do the work and the # 0 0 0 0 0 8 structure is not intended or offered for sale (Section CITY Sapj G� ie TEL. NO.. „7�'�3 7044,Business and Professions Code). P � Q �'t' E+ 2 2700 . ❑ i OWNER I, as owner of the property, am exclusively contracting with licensed contractors to construct the project MAILy^ =0 0 0 2 7,0 0 (Section 7044,Business and Professions Code). ADDRESS I v l /3 Jf �se CONSTRUCTION LENDING AGENCY 5 CITY '� C�-� TEL.NO. �� 77 08,07-81 I herebyaffirmthat there is a construction lending agency CONTRACTOR C L O for the performance of the work for which this permit is l F OM11A PDaL s d4 issued(Sec.3097,Civ.C.). Lender's Name ADDRESS L 4s T A $ I Lender's Address CITY s 4 Q TEL.NO. 7`7-9 S I certify that I have rea this application and state that the STATE LIC. aaboveinmation' o t.I agree to comply with all County LICENSE NO. Seo Z CLASSCsand to a s regulating Heating,Ventilating and ni reby authorize repre:entat' es of this SEE REVERSE FOR EXPLANATORY LANGUAGE t i on the above-mention dp perry for i ses rmit a Date I