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Home My Public Portal About4955 PERSIMMON AVE_Mechanical__ WORKERS' COMPENSATION DECLARATION . I l; �lebaffPrm ,�,�t,I k4a �uerti€irate af.cansellt to seltu e APPLICATION FOR PERMIT insur3 ora ce,ti icate of Vyo�kers' Cc�.mpensgtion Insurance, HEATING - VENTILATING - AIR CONDITIONING or certified copy COMP NSA 3801'! Lab. �rj 76A369C 20-0046 DPW 9/88 Policy No. 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 tion department. (PRINT OR TYPE ONLY) ADDRESS 9, � pC�/^Sr i�h m�� '1rf Date Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY• Tem• C �,� l CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST If 10 L(ThiCOMPENSATION INSURANCE CROSS ST. Ave- (This s section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO. PR D sY the permit is for one hundred dollars(;100)or less.) I certify that in the performance of the work for which this AIR HANDLING UNIT, CFM G D permit is issued, I shall not employ any person in any manner so as to become subject to the Workerg'Compensation Laws. BOILER, BTU APPROVALS DATE INSPECTOR'S NATURE 12 - ly ' 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 VALIDATION with comp)y with such provisions or this permit'shall be deem- �s n ed revoked. FURNACE: FAU GRAVITY �,/tA/ - LICENSED CONTRACTORS DECLARATION FLOOR BTU J 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. T/rC64 14A Q 0 �j-� , d r.License Number Lic. Class pop. U Contractor Date oe ❑ I am exempt under Sec. U Plan check fee u, B.&P.C. for this reason CL PERMIT ISSUING FEE $ 3 W 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): El I, as owner of the property, or my employees with ADDRESS wages as their sole compensation,will do the work and ACCT°4 the structure is not intended or offered for sale(Section CITY TELNO. 3307 49.130 7044, Business and Professions Code). OWNER ' I, as owner of the property, am exclusively contracting 1 ITEMS with licensed contractors to construct the project (Sec- MAIL r, w tion 7044, Business and Professions Code). ADDRESS TOTAL 49.00 CONSTRUCTION LENDING AGENCY CITY TEL. NO. I hereby affirm that there is a construction lending agency for CHECK 49.04i the performance of the work for which this permit is issued CONTRACTOR , CHANGE .00 (Sec. 3097, Civ. C.). Lenders Name /10 4 e ADDRESS CITY r TEL.NO. OOCiO—V�I?i 1 .TCI Lenders Address I STATE V LIC. 2927 1 AM3 ' 1 certify that I have read this application and state that the 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 Aon the o�d property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent Date WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT .�I hereby affirm that I have a certificate of consent;'to;Pelf + fit,'" ' insure, or a certificate of WorkeFs'Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING or a certified cgpy thereof (Seca 3800, Lab. C.) �° 76A364C 20-0046 DPW 9/88 Policy No. ' 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 tion department. !! ff �. �• (PRINT OR TYPE ONLY) ADDRESS Date Applicant LOCALITY �• CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CROSS sr. COMPENSATION INSURANCE (This section need not be completed If the work involved by ABSORPTION UNIT, BTU, DISTRICT NO. PR S D BY the permit is for one hundred dollars($100) or less.) I certifythat 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 to as to become subject to the Workers'Compensation Laws. BOILER, BTU APPROVALS DATE INSPECTOR'S SIGNATURE Date Applicant COMPRESSOR, BTU ROUGH NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL l-P_RP 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 deem- ed revoked. FURNACE: FAU GRAVITY LICENSED CONTRACTORS DECLARATION FLOOR BTU I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED-UNIT- (commencing USPENDED UNIT_ 0CI (commencing with Section 7000)of Division 3 of the Business WALL cma• and Professions Code,and my license is in full force and effect. } License Number _Uc. Class , d O U Contractor Date 0 ❑ I am exempt under Sec. I.- Plan check fee U B.✓3P.C. for this reason O H Date: PERMIT ISSUING FEE $ in Signature TOTAL FEE OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT 1 hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and NAME Professions Code):' F-1 1, as owner of the property, or my employees with ADDRESS wages as their sole compensation,will do the work and Y -� ACCT.e V the structure is not intended or offered for sale(Section CITY TEL.NO. �( 37.007044, Business and Professions Code). OWNER ® I, as owner of the property, am exclusively contracting 1 ITEMS with licensed contractors to construct the project (Sec= MAIL tion 7044, Business and Professions Code). ADDRESS TOTAL 37 00 CONSTRUCTION LENDING AGENCY CITY TEL. NO. I hereby affirm that there is a construction lending agency for CHECK 37.00 the performance of the work for which this permit is issued CONTRACTOR ® CHANGE .00(Sec. 3097, Civ. C.). ADDRESS Lender's Name Lender's Address CITY TEL.NO. 0000-0001 4/23/90 I certifythat I have read this application and state that the STATE LIC. 02595 1 AM10-12C1 PP 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 abov -me 'oned property for ins ection purposes. r p SEE.REVERSE FOR EXPLANATORY LANGUAGE V Signature of Applicant or Agent Da e