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HomeMy Public PortalAbout5544 PERSIMMON AVE_Mechanical__ iVORKERg'COMPENSATION DECLARATION APPLICATION FOR PERMIT trebyl3ffirm that I have a certificate of consent to self i sure, or a eertificatlof Workers'Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING a certifie co thereof (Sec. 3800, ab. C.) 76A364C ff 7 `� CE-818(REV. 10/81) Policy No F/S �mpany �+` N t M 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 S—r / e� 14 tion department. (PRINT OR TYPE ONLY) ADDRESS 7 Date Applicant LOCALITY e-M �,P 0 NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST COMPENSATION INSURANCE CROSS ST. PROCESSED BV (This section need not be completed If the work Involved by ABSORPTION UNIT, BTU DISTRICT NOl the permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM I certify that in the performance of the work for which this t/ permit is issued, I shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws. BOILER, BTU APPROVALS DATE INSPfR'S SI NATURE I COMPRESSOR,BTU 4 7 t OOU d 00 ROUGH ate Applicant OTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL emption, you should become subject to the Workers' mpensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATIO h comply with such provisions or this permit shall be med revoked. FURNACE: FAU Ggg�g,VITY 31 ®/� LICENSED CONTRACTORS DECLARATION 1 FLOOR BTU 7t7F QOO // (/ by affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT encing with Section 7000)of Division 3 of the Business WALL ofessions Code,and my license is in full force and effect. Number 5/a 371 S Lic. Class e , � f; -tor iL�vil/NOQ Date 7" S V //J� am exempt under Sec. 0. Plan check fee .&P.C. for this reason PERMIT ISSUING FEE$ 6 ;22463A Date: TOTAL FEE AS660 54--40 # o o o 0 0 8 ignafure OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT 1 0 a 3 Q 5 0 y affirm that I am exempt from the Contractor's License , the following reason (Section 7031.5, Business and NAME aaa3Q50-5 ns Code): s owner of the property, or my employees with ADDRESS es as their sole compensation,will do the work and CITY TEL. NO. 7, 1 6-85 iructure is not intended or offered for sale(Section Business and Professions Code). OWNER owner of the property, am exclusively contracting MAIL r licensed contractors to construct the project (Sec- ADDRESS 7044, Business and Professions Code). u ` ) CONSTRUCTION LENDING AGENCY CITY TEL. NO. affirm that there is a construction lending agency for , rmance of the work for which this permit is issued CONTRACTOR 670 N o& e C 7, Civ. C.). ADDRESS L12 N er's Name r, (, `) der's Address CIN ��� �Q TEL. NO. ({f�`r a 7 E STATE �/ LIC. /� certify that I have read this application and state that the LICENSE NO. Yoh .�S 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 the above-mentioned property for inspection.purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE \Signature of Applicant or Agent Date 76A364 CE818 ' 3-69 • APPLICATION FOR PERMIT HEATING - VENTILATING - AIR CONDITIONING COUNTY OF LOS ANGELES fNEAREST LDING ;�� �1 ��r,s Iyl ry�f�h /�V L, DEPARTMENT OF COUNTY ENGINEER RESS `7 BUILDING AND SAFETY DIVISION JOHN A. LAMBIE, COUNTY ENGINEER CALITY 1 COLEMAN W.JENKINS,SUPERINTENDENT OF BUILDINGSS ST. Q FOR APPLICANT TO FILL IN OWNER /Y `-fh , %8axr ,a •Lo (PRINT OR TYPE ONLY) I ,I /� NO. TYPE OF APPLIANCE OR EQUIPMENT FEE ADDRESS575 4 �`e,✓SI mY✓lovt Av a— ABSORPTION SYSTEM, BTU CITY "-0—✓� �'e ��( TEL. NO. .. .yZ'�� CONTRACTOR AIR HANDLING UNIT, CFM ADDRESS BOILER, HORSEPOWER CITY TEL. NO. COMPRESSOR, HORSEPOWER STATE LIC. LICENSE NO. CLASS e VENTILATION SYSTEM DISTRICT NO. GROUP ZONE PROCESSED BY EVAPORATIVE COOLER �r FURNACE: FAU GRAVITY t / f FLOOR BTU ©� INSPECTION RECORD HEATER: SUSPENDED UNIT WALL n C L o� C H L LL i n. NEW_ADDITION_ PERMIT $ 3 00 Z ALTEREPAIR_ TOTAL FEE $ ©a F PLAN CHECK APPLICANT NAME ADDRESS CITY TEL.NO. A<oo I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION f] AND STATE THAT THE ABOVE 13 CORRECT AND AGREE TO COMPLY i WITH ALL ORDINANCES AND LAWS REGULATING HEATING,VENTI- LATING, Al CONDTIONING. APPROVALS DATI S ECTOR'3,S.IGNATURE R I I HEREBY CERTIFY THAT 1 AM NOT ACTING IN VIOLATION OF ROUGH „I f��d/lA CHAPTER 9, DIVISION 3, OF THE BUSINESS AND PROFESSIONA FINAL CODE OF THE STATE OF CALIFORNIA. c SIGNATURE ,LACK R. ALLEN, SUPERVrCK CHANICALVENG'R. OF PERMITTEE 2��22 ol PERMIT VALIDATION M.O. CASH PLAN CHECK VALIDATION .0ON= I arr„ 0 2 9 773 APR 2 4 1 0 8.00- --E E BACK OF APPLICATION FOR COMPLETE FEE SCHEDULE v WORKE�P6'COMPENSATION DECLARATION APPLICATION FOR PERMIT I hereby affirm flat-I have a certificate of consent to self insure, or-a certificate of Workers'Compensation Insurance, HEATING -VENTILATING - -AIR CONDITIONING o�a certified copy thereof(Sec. 3800, Lab. C.) 76A364C CE-818(REV. 10/81) Policy No. Company 'I COUNTY OF LOS ANGELES BUILDING AND. FETY Certified copy is hereby furnished. Certified copy is filed with the county building insp - I FOR APPLICANT'TO FILL IN BUILDING aepartment. ADDRESS(PRINT OR TYPE ONLY) Date Applicant LOCALITY NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST COMPENSATION INSURANCE CROSS ST. (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.) I 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 so as to become subject to the Workers'Compensation Laws. f BOILER,BTU APPROVALS DATE INSPECTO SIGNATURE i Date Applicant COMPRESSOR,'BTU ROUGH 0, 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 VALIDA IO with comply with such provisions or this permit shall be deemed 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 with Section 7000)of Division 3 of the Business A AWALL and Professions Code,and my license-is in full force and effect. i) License Number Lic. Class. (/ ► U Contractor Date ❑ I am exempt under Sec. I U :Plan check feeIL IL B.BP.C. for this reason' ;27'$6'5 A Date: � PERMIT ISSUING-FEE$ S # a,o•o o'o $ Signature TOTAL FEE - OWNER-BUILDER DECLARATION 'PLAN CHECK APPLICANT 'I' °0 0 2 a 5.0 1 hereby affirm that I am exempt from the Contractor's License ► Law for the following reason (Section 7031.5, Business and NAME '0 - - 20.5056 Professions Code): ❑ I, as owner of the property, or my employees with ADDRESS -09.08-87 9,O$e.$7 NO. wages as their sole compensation,will do the.work and t the structure is not intended or offered for sale(Section CITY TEL. 4� 7044, Business.and Professions Code). OWNER ❑ I, as owner of the property,am exclusively contracting MAIL with licensed contractors to construct the project (Sec- ADDRESS Tion 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY CITY G TEL. NO. I hereby affirm that there is a construction lending agency for Pool performance of the work for which this permit is issued CONTRACTOR (Sec. 3097, Civ. C.). ADDRESS Lender's Name • CITY TEL. NO. Lender's Address STATE LIC. ® I certify that I have read this application and state that the LICENSE NO. �� CLASS Lam! 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 I upon the a, ove-m ntioned property for.inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of-Applicant or Agent Dote