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Home My Public Portal About6025 MUSCATEL AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT i'■r,,l.bereby rft7m that I'have a certificate of consent to self arKtsure, or,a certificate of Workers'Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING a certified copy thereof(Sec. 3800, Lab. C.) 76A364C 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 c my ul Ing inspec- FOR APPLICANT TO FILL IN BUILDING p tion department. ADDRESS 1pQa (� (PRINT OR TYPE ONLY) Date Applicant LOCALITY NO.. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMP1`10 ROM WORKERS' NEAREST ' COMPENSATION INSURANCE CROSS ST. (This section need not be completed If the work involved by ABSORPTION UNIT,BTU DISTRICT NO. c/ PROCESSED BY the permit is for one hundred dollars.($100)or less.) AIR HANDLING UNIT,CFM d Y C—' V I certify that in the performance of the work for which this a permit is issued, I shall not employ any person in any manner BOILERBTU so as to become subject to the Workers ,Compensation Laws. - APPROVALS DATE I P TOR'S SIG TURE Date ApplicantCOMPRESSOR, BTU (0ow v ROUGH >- NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDA ON with comply with such provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY �{ LICENSED CONTRACTORS DECLARATION FLOOR BTU G V V I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT '(commencing with Section 7000) of Division 3 of the Business - WALL and Professions Code,and my license is in full force and effect. License Number Lic. Class , V �i 0 Contractor Date -f'-22 ❑ I am exempt under Sec. U8 Plan check fee IL IL Date: B.&P.C. for this reason' PERMIT ISSUING FEE$ 9 4 4,7"A _ Signature TOTAL FEE #^0 6 0 0 0'8 OWNER-BUILDER DECLARATION PLAN.CHECK APPLICANT �� I hereby affirm that I am exempt from the Contractor's License , ) ° 7J 0,50 Law for the following.reason (Section 703.1.5, Business and NAME Professions Code): a a e 3 0.5 0'66 ❑ 1, as owner of the property, or my employees with ADDRESS wages as-their sole compensation,will do the work and CITY TEL.NO. the structure is not intended or offered for sale(Section. 4,2 2"8�8 7044, Business and Professions Code). E:] OWNER HCS I, as owner of the property.,am exclusively contracting MAIL with licensed contractors to construct the project (Sec- ADDRESS tion 7044,-Business and Professions Code). CONSTRUCTION LENDING AGENCY CITY4:—�(71'tA/ Vvtl� l"C_� TEL. NO. I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued CONTRACTOR -} S , (Sec. 3097, Civ. C.).' n -R1Uc -&,y' ADDRESS t L . � e Lender's Name CITY . TEL. NO-13—Z S S'a/ 'Lender's Address STATE LIC.I certify that I have read this application and state.that the LICENSE NO. � 05CLASS above 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-mentio ed property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE A� I, -. n•ture of Applicant or Agent Date , WORKER'S COMPENSATION DECLARATION i7BA346DPW 9/88 APPLICATION FOR PERMIT LIME GREEN I hereby affirm that I have a certificate of consent to self insure, I7SA364C or a certificafe of Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING copy thereof(Sec.3800 Lab.C.) 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 PDDR SS DING � I v S ,M(AS ZU1 �Q. department. (PRINT OR TYPE ONLY) Date Applicant LOCALITY NO. TYPE OF APPLIANCE OR EQUIPMENT FEE NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' C OSS ST. COMPENSATION INSURANCE ABSORPTION UNIT,BTU ASSSOR (This section need not be completed if the work Involved by the MAP OOK PAGE PARCEL permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO. PROCESSED BY I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to BOILER,BTU become subject to the Workers'Compensation Laws. 11 ,1' xeer; COMPRESSOR,BTU APPROVALS DATE INSPECTOR'S SIGNATURE Date Applicant VENTILATION SYSTEM NOTICE TO APPLICANT: If, after making this Certificate of ROUGH Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER FINAL provisions of the Labor Code,you must forthwith comply with such provisions or this permit shall be deemed revoked. RNACE: FAU GBPVITY y LICENSED CONTRACTORS DECLARATION FLOOR BTU v�j��— 1 6, VALIDATION I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED—UNIT— (commencing USPENDED UNIT. (commencing with Section 7000)of Division 3 of the Business ander WALL Professions Code,and my license is in full force and effect. License Number LIC.Class a Contractor Date L ❑ I am exempt under Sec. Plan check fee Q BAP.C.for this reason PERMIT ISSUING FEE$ Date: TOTAL FEE LL Signature PLAN CHECK APPLICANT Cr OWNER-BUILDER DECLARATION z 1 hereby affirm that I am exempt from the Contractor's License Law NAME , for the following reason(Section 7031.5, Business and Professions Cod ) ADDRESS I.• ,T I, as owner of the property, or my employees with wages _; e ..,xTTT 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). OWNER Ce%C a tll I, as owner of the property, am exclusively contracting MAIL ,; —{ - „�._r 4 Q with licensed contractors to construct the project (Sec- ADDRESS LP��C.�1(J M us \ Uc- tion 7044,Business and Professions Code). (cc, }'- -^ - CONSTRUCTION LENDING AGENCY CITY11 (� Q TEL.NO. I hereby affirm that there is a construction lending agency for the performance of the work for which this permit Is issued CONTRACTORr.0�/ (Sec.3087,Civ.C.). ADDRESS Lender's Name CITY TEL.NO. Lender's Address I certify that I have read this application and state that the above LICENSE NO. CLCASS j 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 per fq�nspectia ureas s. SEE REVERSE FOR EXPLANATORY LANGUAGE DATE SIGNATURE OF APPLICANT OR AGENT WORKERS' COMPENSATION DECLARATION APPLICATION FOR PERMIT I hereby affirm that I ,jiave,a 4ertificate of consent to self insure, or a certificate of Workers' Compensation Insivdnce, HEATUG - VENTILATING - AIR CONDITIONING or a cer4ified copy thereof (Sec. 3800, Lab. C.) _ 20 004 C I 1 55 M�, Q 20 0046 DPW 9/88 Policy o Company --a'*vYl� Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY ❑ Certified copy is filed with thecounty buildi�gVnpec- FOR APPLICANT TO FILL IN BUILDING tion department. ADDRESS ye 'PRINT OR TYPE ONLY) Date — t ApplicantLOCALITY`^ 0-1 NO. TYPE OF APPLIANCE OR EQUIPMENT FEE v 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 PR EDBY � the permit Is for one hundred dollars ($100)or less.) +/ al / 1 certify that in the performance of the work for which this AIR HANDLING UNIT, CFM J 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 INSPECTOR'S SIGNATURE Date Applicant COMPRESSOR, BTU ROUGH NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL1A IAIA Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER V A with comply with such provisions or this permit shall be deem- ed revoked. FURNACE: FAU GRAVITY LICENSED CONTRACTORS DECLARATION FLOOR BTU I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT (commencing with Section 7000)of Division 3 of the Business WALL and Professions Code,and my�license is in full force and effect. ve�T, r �j� (7 P f2 License Number! /t–;I-� Lic. Class es `` ® O Contractor�zD-6r`5"-` &ate 17 V 0 T � 1 ad ❑ I am exempt under Sec. 0 Plan check fee `V„ B.&P.C. for this reason / w Date: PERMIT ISSUING FEE $ FA Signature TOTAL FEE If 7 OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and NAME Professions Code): r _ ❑ I, as owner of the property, or my employees with ADDRESS Z_S wages as their sole compensation,will do the work and CITY TEL. NO the structure is not intended or offered for sale(Section g 7044, Business and Professions Code). OWNER ❑ I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec- MAIL .. _ 17 . 00 moi: tion 7044, Business and Professions Code). ADDRESS i i='_ �7 C lL CONSTRUCTION LENDING AGENCY CITY TEL NO 7, 'Ir I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued CONTRACTOR D. S ® _:'iii';'?r o_•': (Sec. 3097, Civ. C.). ADDRESS Lender's Name `,� `_�f� CITY – TEL NO�)4' - Lender's Address STATE LIC. I certify that I have read this application and state that the LICENSE NO. �j� CLASS above information is correct. I agree to comply with all County ordinances and State laws relating to building construction, and ereby authoriz r presentatives of this County to enter up a above-me 1 ed property for inspection purposes. 7_�� SEE REVERSE FOR EXPLANATORY LANGUAGE gnature of Applicant or Agent Date y f