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Home My Public Portal About9207 OLIVE ST_Mechanical__ Win RS'COMPENSATION DECLARATION CEA 818 (2-80) APf� C`T CION FOR r E R i�'l] T I hlrrby _) that I have a' certificate of consent to self .+ i .insure,or a certificate of Workers'Compensation insur,'pce,or �. HEATING-VENTILATING-AIR CONDITIONING a certified�cq�p th of(S c 00 ab.C.) ✓ G 6d'�k . � �G _m/ ,3 a'q Policy No. ompany- �/dC/l7d,tl/ i / 1 Certified copy is hereby furnished. �n COUNTY OF LOS ANGELES BUILDING AND SAFETY Certified copy is filed with the county bailding inspection FOR APPLICANT TO FILL IN BUILDING ,q ,Q .• Q depar ment. ®' ®® ADDRESS f/ eg;r L Date Applicant. (PRINT OR TYPE ONLY) LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' NOt TYPE OF APPLIANCE OR EQUIPMENT FEE ' COMPENSATION INSURANCENEAREST CROSS ST. ,�yC/Nl7-4 } (This section need not be completed if the work involved ABSORPTION UNIT, BTU O. by the permit is for one hundred dollars (5100) or less.) DISTRICT NO. PROCES S ED BY O 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 J V d 0 so as to becomd subject to the Workers' Compensation Laws. BOILER,BTU - .APPROVALS DATE INSP TOR'SSIGNATURE Date Applicant COMPRESSOR,BTU. 1200 0 g3 es d ROUGH NOTICE TO APPLICANT: If, after making this Certificate ofVENTILATION SYSTEM U) Exemption, you should become subject to the Workers' FINALr 17J I z Compensation provisions of.the Labor Code, you must-forth- EVAPORATIVE COOLER VAI IDA N . with comply with such provisions or this permit shalt be deemed revoked. FURNACE: FAU GRAVITY LICENSED CONTRACTORS DECLARATION FLOOR: BTU O '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. ��// Jr'ooewl Od%.�C%s 7 License Ndmber /&-Lic.Class C 12 d o?r 7a-.4,J 4e',e y.✓�eT5. d Contractorol? A//?e Date G F1 I am exempt from the licensing requirements as I an a licensed architect or a registered professional engineer Plan check fee 25%of above. -acting in my professional capacity (Section 705.1, Bus- iness and Professions Code). d 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 7. 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 r CITY - structure is not intehded or offered for sale (Section TEL.NO. +_;.. 7044,Business and Professions Code). GnlN�S �17R rr I, as owner of the property, am exclusively contracting OWNER with licensed contractors to construct the project MAIL 'i•'7' (Section 7044,Business and Professions Code). ADDRESS its DA iv-e— _ CONSTRUCTION LENDING AGENCY CITY r--mete- t' TEL.NO.. Pdd..16, 3 I hereby affirm that-there is a construction lending agency for the performance'of the work for which this permit is CONTRACTOR �^ e issued(Sec.3097,Civ.C.). Lender's Name ADDRESS �lr� �, &Cb V& PL t _ Lender's Address .90-01 _- CITY G101Jl,Jj� TEL.NO.. - 1 I certify that I have read this application and state that the. STATE I LIC.- above information is correct.1 agree to comply with all County LICENSE NO. 3 ��o 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 iiispeWiSn,pWposes. z s� Signattife.of Permittee Date _ WORKERS'COMPENSATION DECLARATION CEA 61 BC(2-80) Q��D®II ty ®� 11711 B Il I hereby affirm that I have a certificate -of consell+(to self - insure,or a certificate of WorlCers'Compensation Insurance,or HEATING-VENTILATING CONDITIONING a certified o y therjof(See.3800,L_a�C_.) r-' �( Policy No�Company 11 T' Certified copy is hereby furnished. ;I COUNTY OF LOS ANGELES BUILDING AND SAFETY , Certified copy is filed wit th co my build' in^ ection S i FOR APPLICANT TO FILL IN ADDRESS I' Date ; � Applicant (PRINT OR TYPE ONLY) CERTIFICATE OF EXEM ON FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY COMPENSATIO 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. PROCESS 9Y V I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM r/ permit is issuedi I shall not employ any person in any manner D �- Q d O so as to become subject to the Workers' Compensation Lawsi BOILER, BTU Iii- APPROVALS DATE INSPECTOR'S SIGNATURE W Date Applicant COMPRESSOR,BTU N ROUGH NOTICE TO APPLICANT: If, after making this Certificate of, VENTILATION SYSTEM " Z Exemption, you should become subject to the. Workers' FINAL Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER e O VALIDATION with comply with such provisions or this permit shall b� OC deemed revoked. FURNACE: FAU GRAVITY LICENSED CONTRACTORS DECLARATION FLOOR: BTU --- I hereby affirm that I am licensed under provisions of Chapter HEATER: SUSPENDED UNIT �b 9 (commencing with Section 7000)of Division 3 of the Busi- WALL ness and Professions Code, and my license is in full force an effect. fI .License Number: Lic.Classc—- S3 � ContractQr, 4"-NkCFhT'C Date I am exempt from the licensing requirements as I am 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). 1 PERMIT ISSUING FEE Lic.or Reg.No. Date ! TOTAL FEE 50 HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT I hereby affirm. that 1 am exempt from-the Contractor'? NAME License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): ! ADDRESS I, as owner of the property, will do the work and the structure is not intended or offered for sale (Section CITY TEL. NO. 5 2 1,8 n 7044,Business and Professions Code). as owner of the OWNER 0 0 0 0 0 I %? property, am exclusively contracting n with licensed contractors to construct the project' MAIL 2 1 2 0 - 3350 (Section 7044,Business and Professions Code). I ADDRES J CONSTRUCTION LENDING AGENCY CITY TEL.NO , I a o ; 5 C v I hereby affirm that there is a construction lending agency. I for the erformance of 'the work for which this ermit ( CONTRACTOB. 127-82 issued SSec.3097, Civ.C.). p l l7 Lender s Name ADDRESS V Lender's Address TEL. O. A�uj5 1 certify that I have read this application and state that the STATE . y� above information is correct.I agree to comply with all County LICENSE NO �` _ CLLICAS ordinances and State laws regulating Heating, Ventilating and ' Air Con 'tioning,and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE. County t enter Pon the above-mentioned property foil iu, ecti urpos s. n ture of Permittee Date