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Home My Public Portal About6118 MUSCATEL AVE_Mechanical__ WORKER'S COMPENSATION DECLARATION �66A964CPW 9/89 APPLICATION FOR PERMIT l �•!1 (' l� F\]I hereby affirm that I have a certificate of consent to self insure, 1 1, ; i, u 1 E or a certificate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING �L 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. 11 C rtit' d copy is filed with the county building inspection FOR APPLICANT TO FILL IN BUILDING �s (PRINT OR TYPE ONLY) ADDRESS a Applicant LOCALITY NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST COMPENSATION INSURANCEABSORPTION UNIT,BTU CROSS ST. (This section need not be completed if the work Involved by the ASSESSORMAP BOOK PAGE PARCEL permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO. PROCESSED BY I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to BOILER.BTU eCompensation becomsub'ect to the Workers'Com ensation Laws. ///, t/f- COMPRESSOR,BTU V �� Date Applicant "N :r ellfm 1 APPROVALS DATE INSPECTOR'S SIGNATURE 1 VENTILATION SYSTEM NOTICE TO PPLICANT: If, after making this Certificate of ROUGH Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER provisions of the Labor Code,you must forthwith comply with such FINAL /J provisions or this permit shall be deemed revoked. FURNACE: FAU R9 Q VALIDATION LICENSED CONTRACTORS DECLARATION FLOOR BTU ®®�+(� I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT (commencing with Section 7000) of Division 3 of the Business and HEATER: WALL Professions Code,and my license is in full force and effect. 6ty q License Number 6� � � Lic.Clask5. ACCTnA ®dU� •�G�®i�Gf ' Poll. 3303 114.10a Contractor Date 1 ITEM C; r_1I am exempt Grader See. Plan check fee TOTAL 114. 1,Da B.&P.C.for this reason PERMIT ISSUING FEE$ pC Date: TOTAL FEE _ CHECK 114°10 LL Signature //��v CHANGE v00 v OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT �b�9 3G_ 1 hereby affirm that I am exempt from the Contractor's License Law NAME ODUO_OOQ1 10� for the following reason (Section 7031.5, Business and Professions 'fin 0/ Code): ADDRESS 032 1 A 111-023 ❑ 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). OWNER ❑ 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 CITY '�`� TEL.NO. I hereby affirm that there is a construction Ienpding agency for CONTRACTOR , I he performance of the work for which this ermlt s Issued J (Sec.3097,Civ.C.). ADDRESS Lender's Name O � CITY G� TEL.NO. Lender's AddressT I certify that I have read this application and state that the above LICENSE NO. Gi/ CCLASS 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 u77; ov -mentioned property for"Inspection p oses. / SEE REVERSE FOR EXPLANATORY LANGUAGE ATUR APPLICANT OR AGENT DATE WORKER'S COMPENSATION DECLARATION" 7W64C DPW 9/89 APPLICATION FOR PERMIT LIME GREEN 76A3f34 I hereby affirm that I have a certificate of consent to self insure, or a certificate 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 BUILDING department. (PRINT OR TYPE ONLY) ADDRESS pateApplicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' NEAS ST CROSS ST. COMPENSATION INSURANCE ABSORPTION UNIT,BTU (This section need not be completed if the work Involved by the ASSESSOR p� permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM MAP BOOK a PAGE �l PARCEL ONJ 1 certify that in the performance of the work for which this permit DISTRICT NO. 56 PR is issued, I shall not employ any person in any manner so as to BOILER,BTU 570vv become subject to the Workers'Compensation Laws. q- � n C�. COMPRESSOR,BTU APPROVALS DATE INSPECTOR'S SIGNATURE Date G — 956 Applicant- T-e U., L` � VENTILATION SYSTEM ��v sz� NOTICE TO APPLICANT: If, after making this Certificate of ✓ U� ROUGH Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER provisions of the Labor Code,you must forthwith comply with such FINAL provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDA ION I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT �0 (commencing with Section 7000)of Division 3 of the Business and WALL �/ Professions Code,and my license is in full force and effect. License Number J /S_11�O / Lic.Class T v Contractors—�P/L �` Date 6$-/3// /1 , C ❑ I am exempt under Sec. Plan check fee C D B.&P.C.for this reason PERMIT ISSUING FEE$ Z(p H Date: TOTAL FEE C Signature PLAN CHECK APPLICANT U, OWNER-BUILDER DECLARATION 6 I hereby affirm that I am exempt from the Contractor's License Law NAME 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. _.y__ structure is not intended or offered for sale (Section 7044, :I E, Business and Professions Code). OWNER ❑ I, as owner of the property, am exclusively contracting )l;(ril91- 15 with licensed contractors to construct the project (Sec- ADDRESS 1-HECK i° :I tion 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY CITY TEL.NO. 11CHANGE1_ I hereby affirm that there is a construction lending agency for CONTRACTOR the performance of the work for which this permit Is issued (Sec.3097,Civ.C.). ---1 - y ADDRESS -I_'jij I-.lJ-j it .t :T Lender's Name (.fir( '':,��}'. CITY TEL.NO. Lender's Address STATE LIC. I certify that I have read this application and state that the above LICENSE NO. CLASS 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 property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE SIGNATURE OF APPLICANT OR AGENT DATE