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Home My Public Portal About9135 OLEMA ST_Mechanical__ WORKERS'COMPENSATION DECLARATION t 76A364C • CE-81[3(2-a0) APPLICATION FOR PERMIT I hereby affirm that I have a' certificate of con3erit t2 self 1 insure, or a certificate of Workers'Compensation Insurance,or HEATING-VENTILATING-AIR CONDITIONING a cetv}ified copa.thereof(Sec.3800,Lab.C.) I l Policy No. Company ' 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. ADDRESS Date Applicant (PRINT OR TYPE ONLY) LOCALITY �[ 7fc) CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE COMPENSATION INSURANCE NEAREST } (This section need not be completed if the work involved ABSORPTION UNIT,BTU CROSS ST. O by the permit is for one hundred dollars ($100) or less.) DISTRICT NO. PROCESSED BY V I certify that. in the performance of the work for which this AIR HANDLING UNIT,CFM permit is issued, I shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws. I BOILER,BTU O APPROVALS DATE INSPECTOR'S SIGNATURE Date Applicant COMPRESSOR,BTU ROUGH —� y NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM p Z Exemption, you should become subject to the Workers' FINAL Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION with comply with such provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY LICENSED CONTRACTORS DECLARATION FLOOR: BTU 1hereby affirm that I am licensed under provisions of Chapter HEATER: SUSPENDED UNIT 9 (commencing with Section 7000)of Division 3 of the Busi• WALL ness and Professions Code, and my license is in full force and effect. License Number Lic.Class Contractor Date I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer Plan check fee 25%of above. acting in my professional capacity (Section 7051, Bus- iness and Professions Code). PERMIT ISSUING FEE$ Lic.or Reg.No. Date TOTAL FEE HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT I hereby affirm that I am exempt from- the Contractor's NAME ,��,t.>v License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): ADDRESSql 1, as owner of the property, will do the work and the �//��a 2 6 1 &5A structure is not intended or offered for sale. (Section CITY TEL.NO Q 7044,Business and Professions Code). o If I 0 0 0 0 $ OWNER I, as owner of the property, am exclusively contracting 4 2 0 0 1 Q.5 0 with licensed contractors to construct the project MAIL (Section 7044,Business and Professions Code). ADDRESS 0 o ol 4 5 0 5 CONSTRUCTION LENDING AGENCY CITY TEL.NO. I hereby affirm that there is a construction lending agency 0 9 13-82 for the performance of the work for which this permit is CONTRACTOR issued(,Sec.3097,Civ.C.). Lenders 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 ordinances and State laws regulating Heating,Ventilating and Air Conditioning,and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE County to enter upon the above-mentioned 'property for d inspection purposes. 4, -��,,;.�o.0 �d ) �cc.w�ch✓ g- a �a 5�gnature of Permittee Date i I hereby 'm that I have a' certificate of consent to self 'I CEA 81 8C WO (2 .80) LLQ�C/ T B®� If- ff i 9C/Il 0T j KERS COMPENSATION DECLARATION insure,or a certificate of Workers'Compensation Insurance,or HEATING-VENTILATING-AIR CONDITIONING a certified copy�ythereof(Sec.3800,Lab.C.) _ Policy Nof�'bA0S_`Company UN!IrA AD V rfcJ 4L I ❑ Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY Certified copy is filed with the county building inspection BUILDING dy ar tn� t. �1� FOR APPLICANT TO FILL IN J Dater '� Applicants �1!'0r &1104&_ 1��/�T (PRINT OR TYPE ONLY) ADDRESS CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY � COMPENSATION INSURANCE NEAREST CROSS ST. �_K d (This section need not be completed if the work involved ABSORPTION UNIT,BTU O by the permit is for one hundred dollars ($100) or .less.) DISTRICT NO. n� FROCEST BY 0 I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM �� )ti W permit is issued, I shall not employ any person in any manner G/Q O so as to become subject to the Workers'Compensation Laws. BOILER, BTU I-_ APPROVALS DATE INSPECTOR'S SIGNATURE W Date Applicant COMPRESSOR,BTU 56o IBJ �� J ROUGH N NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL Z Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION with comply with such provisions or this permit shall be deemed revoked. II LICENSED CONTRACTORS DECLARATION U FURNACE: FAU AV�ix — /,9 0rj FLOOR: BTU I hereby affirm that I am licensed under provisions of Chapter HEATER: SUSPENDED UNIT 9 (commencing with Section 7000)of Division 3 of the Busi- WALL ness and Professions Code, and my license is in full force and effect. /y, h License Nuufm,b��er �L�4' ,�r Laic.Class-L_1-6'9 Contractdrr�C.��N0/.>�/_�__11 Date_!l- etc YD ❑ I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer Pian check fee 25%of above. acting in my professional capacity (Section 7051, Bus- iness and Professions Code). PERMIT ISSUING FEE$ 7 dt7 I Lic.or Reg.No. Date TOTAL FEE Z? HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT I hereby affirm that I am exempt from-the Contractor's NAME License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): ADDRESS ❑ 1, as owner of the property, will do the work and the CITY TEL.NO. structure is not intended or offered for sale (Section 7044, Business and Professions Code). OWNER :23263P 3 ❑ J�-/ytiS h� SQ /V I, as owner of the property, am exclusively contracting with licensed contractors to construct the project MAIL (Section 7044,Business and Professions Code). ADDRESS 1 JS 19 /may �/ CONSTRUCTION LENDING AGENCY CITY TEL.NO. 'Z�� 6/�i7 `� 0 0 2 7.C r' I hereby affirm that there is a construction lending agency CONTRACTOR ( .��6 L - -/ I�-�-Y f U�TIt o n c for the performance of the work for which this permit is I�� f, fc (D issued(Sec.3097,Civ.C.). I• a Lender s Name ADDRESS 7L, Lender's Address CITY �✓ TEL.NO. 1 certify that I have read this application and state that the I STATE above information is correct.I agree to comply with all County LICENSE NO. Cal CLAS ordinances and State laws regulating Heating, Ventilating and + Air Conditioning,and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE County to enter upon the above-mentioned property for inspectionpuSe Z08� C!y ! \ I Signature of Permittee Date