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Home My Public Portal About5947-5947 1/2 PRIMROSE AVE_Mechanical__ L ' �' WORKERS'COMPENSATION DECLARATION 4,her y affirm that I have a certificate of consent to serf APPLICATION FOR PERMIT insure, or a certificate of Workers'Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING or rYcertified copy thereof(Sec. 3800 tab. C.) I 76A364C /J f CE-818(REV. 10/81) Policy N ° ..• /P ❑ COUNTY OF LOS ANGELES BUILD S 1� Certified copy is hereby furnished. Certified copy is filed with the county building inspec- FOR.APPLICANT TO FILL IN BUILDING tion department. ' (PRINT OR TYPE ONLY) ADDRESS 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($100)or less.) LCJ I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM permit is issued,I shall not employ any person in any manner BOILERBTU so-as to become subject to the Workers ,Compensation Laws. APPROVALS DATE INSPE R•S SIGNATURE Date Applicant COMPRESSOR,BTU ®p v� ROUGH I 104�g gold 01 1 1 9 NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL Exemption, you should become subject to the Workers' Compensation provisions-of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION with comply with such provisions or this permit shall be deemed revoked. FiRCE: FAU AVITY /dLICENSED CONTRACTORS DECLARATION � I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED—UNIT- '(commencing USPENDED UNIT'(commencing with Section 7000) of Division 3 of the Business - WALL and Professions Code,and my license is in full force and effect. 0. License Number 6 Lic. Class , f� 009Contractor j Date `� u I am exempt under Sec. Iw Plan check fee on B.BP.C. for this reason' � on PERMIT ISSUING FEE$ Date: q 9'],4 A TOTAL FEE Signature o OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT 0'0 8 I herebyaffirm that I am exempt from the Contractor's License • , Law fothe following reason(Section 7031.5, Business and NAME qJ -°�'TJ f�I C, �� ( 0 0 ]l�'S'� Professions Code): ADDRESS ^7 Q. � 0 0 0 71.5 Q C5❑ I, as owner of the property, or my employees with ` 7 • '/ wages as their sole compensation,will do the work and �•7 o&23-88 the structure is.not intended or offered for sale(Section CITY J� TEL.NO%� 'J� 3�� 7044, Business and Professions Code). OWNER rill, ❑ I,as owner of the property,am exclusively contracting A/ with licensed contractors to construct the project (Sec- MAIL �// / J !: tion 7044, Business and Professions Code). ADDRESS CONSTRUCTION LENDING AGENCY CITY�' Ll TE0111 (5-97 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued CONTRACTOR 44 (Sec. 3097, Civ. C.). ADDRESS Lender's Name 70/ Lender's Address CITY 1 ) STATE LIC. I certify that I have read this application and state that the LICENSE NO. 2 �j CLASS —:20 above information is correct. I agree to comply with all County ordinances and'State laws relating to building construction, and hereby aut rize representatives of this.County to enter nth ab e I ned property for i s e tion p�ose SEE REVERSE FOR EXPLANATORY LANGUAGE i C Signature of Appli t or Agent Date I WORKERS'COMPENSATION DECLARATION L- —3/ �� 4 •r` ' that I, ,ave p certitr�ate of consent to Self: APPLICATION FOR PE MIT .:jms or• .t 3rdificat$of WorKers'Compensation Insurance,; HEATING - VENTILATING - AIR CONDITIONING oro er}ifWNEopy thereof(Sec. 3800, Lab. C.) -76A364C 4 •, •V 'CE-818(REV. 10/81) Policy,No. Company COUNTY OF LOS ANGELES BUILDING ANDSAFETY Certified copy is hereb urnished. ' Ce-'fied copy is filed with h county buil lnspec', FOR APPLICANT TO FILL IN BUILDING _ tion arlment. ' (PRINT OR TYPE ONLY) ADDRESS = Date«�-�Z Applican LOCALITY NO. TYPE OF APPLIANCE OR EQUIPMENT FEE v v�i�► CERTIFICATE OF E'EMPTION FROM WORKERS' NEAREST COMPENSATION INSURANCE CROSS ST. (This section need not be completed if the work involved by ABSORPTION UNIT,BTU DISTRICT NO. PROC the permit is for one hundred dollars($100)or less.) j AIR HANDLING UNIT,CFM I certify that in the performance of the work for which this � Q permit is issued, I shall notemploy ny person in any manner so as to become subject to the o ers'C m ensati n Laws.. BOILER,BTU APPROVALS DATE INSP OR's NAT E Date L l�Applican COMPRESSOR,BTU ROUGH NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER I VALIDATION with comply with such provisions or this permit shall be j deemed revoked. FURNACE: FAU GRAVITY LICENSED CONTRACTORS DECLARATION FLOOR BTU I hereby affirm that I am licensed under provisions of Chapter 9SUSPENDED UNIT' '(commencing with Section 7000)of Division 3 of the Business HEATER: WALL and Professions Code,and my license is in full forces and effect. License Number Ag7tZ& Lic. Class L+2� ' , 0 t11>�si �/ � Contractor o' er= Date I~ 2"L�!/• 1 I am exempt under Sec. LU Plan check fee a BAP.C. for thi eat on PERMIT ISSUING FEE$ z Signatur TOTAL'FEE ,5 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): ❑ I, as owner of the property, or my employees with ADDRESS wages as their sole compensation,will do the work and the structure is not intended or offered for sale(Section CITY TEL. NO. 7044, Business and Professions Code). OWNER - ❑ I, as owner of the property,am exclusively contracting A 5 9 2 3-A with licensed contractors to construct the project (Sec- MAIL tion 7044, Business and Professions Code). ADDRESS # 0 a a a 08 CONSTRUCTION LENDING AGENCY. CITY TEL. NO. - 2275 I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued CONTRACTO BfS• J g�'�r ® T6; Lender's Name (Sec. 3097, Civ. C.). y� •- ^ 0 2275 a . ADDRESS I Er /S iF ,1, 12-86 . CITY TEL. NO. _ 3 Lender's Address 46"1116, STATE LIC. I certify that I have read this application and state that the LICENSE NO. '2 CLASS d 20 above information is correct. I agree to comply with all County or 'nances and State laws relating to building construction, n hereby authoriz representatives'of this County to.enter n th a ov en I ned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE 1 Signature of Applicant or Agent Date i