The URL can be used to link to this page

Home My Public Portal About6220 OAK AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION'~ APPLICATION FOR PERMIT reby affirm that I have a certificate of consent to self I ure, or a certificate of Workers'Compensation Insuranc j6A364C HEATING - VENTILATING - AIR CONDITIONING r certified co y thereo Sec. 38 ab. C.) �� CE-818(REV. 10/81) l Policy o c J Company ❑ Certified copy is hereby furnished. ( COUNTY OF LOS ANGELES BUILDING AND SAFETY. Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING tionde ar t. (PRINT OR TYPE ONLY) ADDRESS 17149 014 LOCALITY ' C Date APP Ica NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST COMPENSATION INSURANCE CROSS ST. t,?� (This section need not be completed If the work Involved by. ABSORPTION UNIT, BTU DISTRICT NO. &F PROCESSED the permit Is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM �7 I certify that in the performance of the work for which this 0'"b permit is issued, I shall not employ any person,in any manner f so as to become subject to the Workers'Compensation Laws. BOILER,BTU APPROVALS DAT' INSPECTOR'S SIGNATURE Date Applicant COMPRESSOR,BTU ROUGH 4-Z ' -f NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL Exemption, you'should become 'subject to the Workers' VALIDATION Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER with comply with such provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY j LICENSED CONTRACTORS DECLARATION FLOOR BTU . I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT ' '(commencing with Section 7000)of Division 3 of the Business - WALL and Professions Code,and my license is in full force aneffect. License Number - I Lic:Class 1 U f ® 19 ContractorQ `_ �1 Date u ❑ I am exempt under Sec. I lu Plan check fee H B.BP.C. for this reason PERMIT ISSUING FEE$ Date: TOTAL FEE ' Signature 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): ❑ I, as owner 6f the property, or my employees with ADDRESS r'9 wages as their sole compensation,will do the work and rowp TEL.NO. a +r o'0 0 0 0 the structure is not intended or offered for sale(Section 7044„Business and Professions•Code). ' ( 7 00 20.50 ❑ l,'os'owner of the property, am exclusively contracting with licensed contractors to construct-the project (Sec- MAIL' tion 7044, Business and Professions Code). ADDRESS �,i5 r CONSTRUCTION LENDING AGENCY CITY _ TEL N ,. I hereby affirm that there is a construction lending agency for 3' 5-84 the performance of the work for which this permit is issued CONTRACTOR IL (Sec. 3097, Civ. C.). - ADDRESS (vim— CX_ Lender's Name1 CITYI TEL. N Lender's Address I certify CL that I have read this application and state that the STATE ' LICENSE NO CLASS 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 ' u o he bove-m tioned property for inspection purposes. SEE REVERSE TOR EXPLANATORY LANGUAGE XD 3 j e I. Signature of Applicant or Agent _ , Date WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT I hereby affirm that I have a certificate of consent to self 'Insure, or®certificate of Workers'Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING or'a certified copy thereof(Sec. 3800, Lab. C.) 76A364C CE-818(REV. 10/81) .P❑olicy No. 580937 Company State Fund Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY Certified copy is filed with t county uil i g inspec- FOR APPLICANT TO FILL IN BUILDING ® tion department. (PRINT OR TYPE ONLY) ADDRESS 622 Qak Ave. Date -Applica LOCALITY NO. TYPE OF APPLIANCE OR EQUIPMENT FEE NEAREST CERTIFICATE OF EXEMPTION ROM WORKERS' CROSS ST. T,nn dell Ave COMPENSATION INSURANCE (This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO. PROCESSED BY the permit is for one hundred dollars(;100)or less.) AIR HANDLING UNIT,CFM I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner BOILER, BTU so as to become subject to the Workers'Compensation Laws. APPROVALS DATE INSPECTOR'S SIGNATURE Date Applicant / COMPRESSOR, BTU � ROUGH NOTICE TO APPLICANT: If, after making this Certificate of I @ VENTILATION SYSTEM FINAL Exemption, you should become subject to the Workers' „ Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VAL DATION with comply with such provisions or this permit shall be deemed revoked. FURNACE: FAU G&AYITY LICENSED CONTRACTORS DECLARATION I FLOOR BTU ,-C'QW'y 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. a License m r Lir. Class C-2 Q_ ® V QC Contrac or �AAto 7-5-91 ❑ Itam exempt under Sec. LU Plan check fee H B.&P.C. for this reason PERMIT ISSUING FEE$ Z Date: Signature TOTAL FEE 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): ❑ I, 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 7044, Business and Professions Code). ---••-. OWNER = i:tS' t ❑ I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec- MAIL am 3 -0tion 7044, Business and Professions Code). ADDRESS CONSTRUCTION LENDING AGENCY CITY TEL. NO. '_ 4 •I'•. ''{=t'-i I hereby affirm that there is a construction lending agency for -,.. the performance of the work for which this permit is issued CONTRACTOR Pilo '_i"A GE_ ==:1: (Sec. 3097, Civ. C.). TED= Ai-r Lender's Name ADDRESS 5937 North Oak Avenue - "_" '� r:'' • CITY T TEL. NO.' 285-1218 Lender's Address i t STATE LIC. E0'51.J _. fli: f+•: I certify that I have read this application and state that the LICENSE NO. 274880 CLASS C-20 above information is correct. I agree to comply with all County ordinances and State laws relating to building construction, and hereby authorize rep sentatives of this County to enter upon a bov -m ti d property for inspection purposes. ' SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant o gent Dote