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Home My Public Portal About6016 PRIMROSE AVE_Mechanical__ WORKERS'-COMPENSATION t I have a ceT N DECLARATION APPLICATION FOR PERMIT I here�y affirm,that I have a 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 CE-818(REV. 10/81) Policy No. Company Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY aq ❑ Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING tion department. 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. PROCESSE"v the permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any mariner so as to become subject to the Workers'Compensation Laws, BOILER;BTU APPROVALS DATE I CTOR'S SIG ATURE /L - DateC pplicant COMPRESSOR,BTU (/� ROUGH v NOTICE TO APPLICANT: If, after making this Certificate ol VENTILATION SYSTEM FINAL. Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION with comply with such provisions or this permit shall be deemed revoked. `7 FURNACE: FAU G 'VITY goo`� LICENSED CONTRACTORS DECLARATION �y FLOOR BTW (J I hereby affirm that I am licensed under provisions bf Chapter 9 HEATER: SUSPENDED UNIT '(commencing with Section 7000) of Division 3 of the.Business - WALL and Professions Code,and my license is in full force and effect. License Numb Lic. Clas9s �L� bf , U Date 7'`,P6 ❑ I am exemp under Sec Plan check fee H B.BP.C. for this reason' � Date: PERMIT ISSUING FEE$ z 51 201A TOTAL FEE Signature # 0 0 0 0 0 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 , ° ° 50.50 Professions Code): ❑ I, as owner of the property, or my employees with ADDRESS wages as their sole compensation,will do the work and o -.0 5(�5 0 0 the structure is not"intended or offered for sale.(Section CITY TELNO. 7044, Business and Professions Code). 07,24--86 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 TEL. NO. I hereby affirm that,there is a construction lending agency for , the performance of the work for which this permit is issued CONTRACTOR (Sec. 3097, Civ. C.). ADDRESS Lender's Name C TEL. NO ��,�j ff 'Lender's Address TATE LIC. I certify that I have read this application and state that the LICENSE NQ CLASS Z 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 upony�bove-mentionedpro erfy for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent Date r Wfirm-t at I hgve a CLION DECLARATION APPLICATION FOR PERMIT irisurebor as certificate of Workers'Compen tion Insurance, or a certified copy thereof(Sec. 3800, Lab. C.) 76A364C. HEATING - VENTILATING - AIR CONDITIONING CE-818(REV. 10/81) Policy No. Company Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY ❑ Certified copy is filed with the county building irispec- 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.) AIR HANDLING CFM UNIT, 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. 2 BOILER,BTU y�/�/� �y�) APPROVALS DATE IN E s SIGNATU E D y e&A licant 1^ COMPRESSOR,'BTU 0dy`-�v (/V ROUGH - 7 pp d NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL - n Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth EVAPORATIVE COOLER VALIDATI N with comply*with such provisions or this permit shall be deemed revoked. FURNACE: FAU VITY 4A /� LICENSED CONTRACTORS DECLARATION 2, FLOOR BT o I hereby affirm that I am licensed under provisions'of Chapter 9 SUSPENDED UNIT '(commencing with Section 7000)of Division 3 of the Business HEATER: WALL and Professions Code,and my license is in full force and effect. �Lice se Numba � d`/ 2•-Lic. Class , V JIM i r Date -- 9511,9A ❑ I am exempt under S O Plan check fee # a o a o o 8 0. B.&P.C. for this reason PERMIT ISSUING FEE I o o 5 Q 5 0 Z Date: Signature TOTAL FEE o o 0 5 a 5 0 5 OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT 7,2 4—S 6 I hereby affirm that I am exempt from the Contractor's License , Low'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. O 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 MAIL with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY CITY TEL. NO. I hereby affirm that there is a construction lending agency for pool performance of the work for which this permit is issued CONTRACTO (Sec. 3097, Civ. C.). ADDRESS212510 Lender's Name Lender's Address 9 -ff ATE LIC. I certify that I have read this application and state that the LICENSE N CLASS G - 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 upon t a v oned property for inspection purposes, SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent Date