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HomeMy Public PortalAbout6202 PRIMROSE AVE_Mechanical__ WORKER'S COMPENSATION DECLARATION 200048DPW 9,B9 APPLICATION FOR PERMIT LIME GREEN 78A364C 4 hereby affirm that I have a certificate of consent to self insure, or a certificate of Worker's Compensatio"Insure o. or a certified HEATING-VENTILATING-AIR CONDITIONING copy thereof(Sec.3800 Lab.C.) Policy No. • Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV. ❑ Certified copy is hereby furnished. ❑ UILDING Certified copy is filed with the county buil ng ins ction FOR APPLICANT TO FILL IN ADDRESS ���r department. (PRINT OR TYPE ONLY) o�- A licant LOCALITY Date �� pP NO. TYPE OF APPLIANCE OR EQUIPMENT FEE NEAREST CERTIFICATE OF EXE N OM WO ERS' CROSS ST. COMPENSATION IN URANCE ABSORPTION UNIT,BTU (This section need not be completed if the wor Involved by the ASSESSOR /� MAP BOOK O PAGED PARCELOa permit is for one hundred dollars($100)or less AIR HANDLING UNIT,CFM DISTRICT NO. PROCESSED BY I certify that in the performance of the work for which this permit is Issued, I shall not employ any person in any mann r so as to BOILER,BTU ,{� p oe become subject to the Workers'Compensation aws. ii �•a0 t COMPRESSOR,BTU ��� g APPROVALS DATE INSPECTOR'S SIGNATURE Date Applicant VENTILATION SYSTEM NOTICE TO APPLICANT: If, afte<5a_k1hg this Certificate of ROUGH Exemption,you should become subject tote Workers' compensation EVAPORATIVE COOLER provisions of the Labor Code, you mus orthwith co ply with such FINAL provisions or this permit shall be deemed revoked. J FURNACE: FAU TY LICENSED CONTRACTORS DECLARATIO / FLOOR BTU © J/ VALIDATION I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT (commencing with Section 7000)of Division 3 of the Business and WALL Professions Code,and my license is in full force and effect. �nGam' License Number v 2 6 1- LID.ClassJI J' 35 > Contractor Date C ❑ I am exempt under Sec. Plan Check fee a C B.&P.C.for this reason PERMIT ISSUING FEE$ J yl ff _ L Date: TOTAL FEE a� LL A-•;• t a Signature_) I °z - V ° PLAN CHECK APPLICANT f OWNER-BUILDER DECLARATION L ti s. I hereby affirm that I am exempt from the Contractor's License Law #1ME j 6r for the following reason(Section 7031.5, Business and Professions v l0/ 1'LDS"r'-� Code): ADDRESS ii [li 6 = C15 I, as owner of the property, or my employees with wage !' -r as their sole compensation, will do the work and th CITY TEL.NO. CHEM structure is not intended or offered for sale (Section 704 , Business and Professions Code). OWNS ❑ 1, as owner of the property, am exclusively contractin MAIL with licensed contractors to construct the project (Se ADDRESS tion 7044, Business and Professions Code). A. CONSTRUCTION LENDING AGENCY CIN TEL.NO. I hereby affirm that there is a construction lending agency for �J 3C the performance of the work for which this permit Is issue ONTRACTOR (Sec.3097,Civ.C.). q p� ADDRESS Z dV Lender's Name CITY TEL.NO. Lender's Address STATE C, (/ LIC. O_ I certify that I have read this application and state that the above LICENSE NO. Gi CLASS Al information is correct. I agree to comply with all County ordinances and State laws rela ing to building construction,and hereby authorize representatives o his C ty to enter upon the above-mentioned property for in urposes. SEE REVERSE FOR EXPLANATORY LANGUAGE �lX/ SIGN REO PPLICANT O AGENT AT LIE GREEN WORKER'S COMPENSATION DECLARATION z0-0046 DPW 9/89 . APPLICATION FOR PERMIT 76A364C 4 hereby affirm that I have a certificate of consent to self insure, - or a certificate of Worker's CompensationInsura ce, or a certified HEATING-VENTILATING-AIR CONDITIONING copy thereof(Sec.3800 Lab.C.) Policy No. • Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV. ❑ Certified copy is hereby furnished. F1 FOR APPLICANT TO FILL IN BUILDING Certified copy is filed with the county buil ng insp9ction (PRINT OR TYPE ONLY) ADDRESS Z-�99. department. Date �` - A Ifcant LOCALITY PP NO. TYPE OF APPLIANCE OR EQUIPMENT FEE NEAREST CERTIFICATE OF EXEMP N OM WO ERS' CROSS ST. COMPENSATION IN URANCE ABSORPTION UNIT,BTU (This section need not be completed if the war In by the ASSESSOR ,{- O� PAGE Q�p� PARCEL�c� MAP BOOK d O permit is for one hundred dollars($100)or less AIR HANDLING UNIT,CFM DISTRICT NO. PROCESSED BY I certify that in the performance of the work for which this permit is Issued, I shall not employ any person in any mannAr so as to BOILER.BTU become subject to the Workers'Compensation kaws. COMPRESSOR,BTU �� _ APPROVALS DATE INSPECTOR'S SIGNATURE Date Applicant VENTILATION SYSTEM NOTICE TO APPLICANT: If, alteR mak' g this ertificate of ROUGH Exemption,you should become subject o t e Workers' ompensation EVAPORATIVE COOLER provisions of the Labor Code,you mus orthwith co ply with such FINAL , provisions or this permit shall be deemed revoked. J FURNACE: FAU-GRAVJTY //� LICENSED CONTRACTORS DECLARATIO / FLOOR BTU It?, b'S VALIDATION I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT (commencing with Section 7000)of Division 3 of the Business and HEATER: WALL Professions Code,and my license is in full force and effect. License Number V 2 LID.Class 3. 01%6?1V?A_ !-1.4re ! ® C Contractor. Date f C ❑ I am exempt under Sec. Platt Check fee Ix C B.&P.C.for this reason PERMIT ISSUING FEE$ Je �0 r Date: TOTAL FEE Signature f ? I °z Cr PLAN CHECK APPLICANT j!J OWNER-BUILDER DECLARATION L.�l.?L `jj'''°''' 1 hereby affirm that I am exempt from the Contractor's License Law E y� j�ilh i for the following reason(Section 7031.5, Business and Professions VK- rT lV�" (f-�'D Coe): ADDRESS p T 106 = 05 1, as owner of the property, or my employees with wage L as their sole compensation, will do the work and th CITY TEL.NO. a� ttiF :�E structure is not intended or offered for sale (Section 704 Business and Professions Code). OWNS CHANGE ❑ 1, as owner of the property, am exclusively contractin MAIL with licensed contractors to construct the project (Be ADDRESS tion 7044,Business and Professions Code). lco tel`>>_(rlt)�J i - +� ' CONSTRUCTION LENDING AGENCY CITY TEL.NO. I hereby affirm that there is a construction lending agency fol -''`? s F �+.•�� the performance of the work for which this permit is issue ONTRACTOR (Sec.3097,Civ.C.). ADDRESS Lender's Name CITY „��7//I,�QZ6 TEL.NO. Lender's Address STATE LIC. I certify that I have read this application and state that the above I LICENSE NO. CLASS information is correct. I agree to comply with all County ordinances and State laws rela Wing to building construction,and hereby authorize representatives o s C ty to enter upon the above-mentioned property for in urposes. SEE REVERSE FOR EXPLANATORY LANGUAGE r� SIG RE qPAPPLICANT OFIAGENT AT