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Home My Public Portal About9578 PENTLAND ST_Mechanical__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT I,hereby affirm tha)"I have a ceriificate'of consent to self insure, or a certificate of Workers' Compensation Insurance, EATING . VENTILATING - AIR CONDITIONING or a certified copy thereof (Sec. 3800, Lob. C.) 76A364C PolicyNo ,5.,� Company -�L^� 20-0046 DPW 9/88 ❑ .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 tion department. ADDRESS `�� ` (PRINT OR TYPE ONLY) Date Nvlx y—i Applicant LOCALITY NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WO ERS' NEAREST COMPENSATION INSURANCE CROSS ST. (This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO. ESSED BY the permit is for one hundred dollars($100)or less.) r)V t J Q I certify that in the performance of the work for which this I AIR HANDLING UNIT, CFM lJo r/rC_ 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 NSPECTOR' SIGNATURE Date Applicant COMPRESSOR, BTU 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 V L T withcomp with such provisions or this permit shall be deem- ed revoked. FLOOR CE: FAU G TY ®( LICENSED CONTRACTORS DECLARATION BTU 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. ino0 License Number M 6A3% Lic. ClassI Poo, O U Contractor Date \� � O ❑ I am exempt under Sec. 11�_ Pla'n check fee U W B.&P.C. for this reason H Date: PERMIT ISSUING FEE $ Z T Signature OTAL 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): ADDRESS ElI, as owner of the property, or my employees with ACCT, wages as their sole compensation,will do the work and CITY TEL. NO. -�-�,31 -+ the structure is not intended or offefed for sale(Section 3 7 ,30.51) 7044, Business and Professions Code). t� ❑ OWNER M I ITE S I, as owner of the property, am exclusively contracting I with licensed contractors to construct the project (Sec- ADDRESS TOTAL 30 .50 m0 tion 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY CITY TEL. NO. = I hereby affirm that there is a construction lending agency for �� f I the performance of the work for which this permit is issued CONTRACTOR CHANGE .00 (Sec. 3097, Civ. C.). ADDRESS Lender's Name CITY1a. TEL. 0000 0001 11/29/8? NO. Lender's Address a I certifythat I have read this application and state that the STATE LIC. 711 1 � 9� 9 PP LICENSE NO. Q CLASS above information is correct. I agree to comply with all County ordinances and State laws relating to building construction, and here athotize-re resentatives of this County to enter up a above-mentiol roperty for inspec ion purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signa ure Applic t or A nt Date I @ WORKERS'COMPENSATION DECLARATION I a APPLICATION FOR PERMIT I,hereby offlFm thar'I'have certificate of"consent to self insure, or a certificate of Workers'Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING or a certified copy thereof(Sec. 3800, Lab. C.) 76A364C ` 20-0046 DPW 9/88 Policy No�'9%�5aCompany_ �►f\(� . F] --Certified copy whereby furnished. i COUNTY OF LOS ANGELES BUILDING AND SAFETY Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING tion department. ADDRESS S '�^vv�� (PRINT OR TYPE ONLY) DateApplicant LOCALITY NO. TYPE OF APPLIANCE OR EQUIPMENT FEE I CERTIFICATE OF EXEMPTION FROM WO ERS' NEAREST COMPENSATION INSURANCE I. CROSS.ST. ABSORPTION UNIT, BTU (This section need not be completed If the Work Involved by DISTRICT Mn ESSED BY the permit is for one hundred dollars ($100)or less.) (/ I certify that in the performance of the work for which this I AIR HANDLING UNIT, CFM C� permit is issued, I shall not employ any person in any manner BOILER, BTU so as td become subject to the Workers'Compensation Laws. APPROVALS DATE NSPECTOR' SIGNATURE Date Applicant COMPRESSOR, BTU ROUGH f NOTICE TO APPLICANT: If, after making this Certificate of ' VENTILATION SYSTEM FINAL el Al AI Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER V L T with comp) with such provisions or this permit shall be deem- ed'revoke' FURNACE: FAU G2MTY 1 O 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. AleI O `1 } License Number 6 l ; Lic. Class , O Contractor Date ❑ I am,exempt under Sec. � Plain check fee u B.&P.C. for this reason. ii Date: I PERMIT ISSUING FEE $ Z 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): u ElADDRESS I, as owner of the property, or my employees with ACCT o s wages as their sole compensation,will do the work and the structure.is not intended or offered for sale(Section CITY!-- TEL. NO. 3 U7 �I�.50 7044, Business and Professions Code). OWNER I, as owner of the property, am exclusively contracting I M TOTAL �PI ITEMS �-um � with licensed contractors to construct the project (Sec MAK - tion 7044, Business and Professions Code). ADDRESS fi�}L CONSTRUCTION LENDING AGENCY CITY TEL.NO.-, I (aa�(J CHECK •-t I hereby affirm that there is a construction.lending agency for the-performance of the work for which this permit is issued CONTRACTOR p CHANGE ,00 (Sec. 3097, Civ. C.). ADDRESS Lender's Name CIT40000-0001 11/29/89 TEL.NO. Lender's Address STATE LIC. 7118 1 Ari 945$ 1 certify that I have read this application and state that the LICENSE NO. above information is correct..I agree to comply with all County O5 CLASS ordinances and State laws relating to building,construction, and here othorize-Fe resentatives of this County to enter j i up he above-mentio roperty for inspec ion purposes. I SEE REVERSE FOR EXPLANATORY LANGUAGE SiSign. ure A 9 pylic t or A nt Date