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Home My Public Portal About10224 RANDWICK DR_Mechanical__ WORKER'S COMPENSATION DECLARATION 46DPW 9/89 APPLICATION FOR PERMIT LIME GREEN 76A3 Thereby affirm that I have a certificate of consent to self Insure, 76A364C or a certificate of Worker's Compensation Insurance,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. ❑ Certified copy Is filed with the county building inspection FOR APPLICANT TO FILL IN BUILDING department. (PRINT OR TYPE ONLY) ADDRESS J0 L-M Date Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST COMPENSATION INSURANCE CROSS ST. ABSORPTION UNIT,BTU ASSESSOR (This section need not be completed if the work Involved by the MAP BOOK PAGE PARCEL permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM I certify that in the performance of the work for which this permit DISTRICT NO. PROCESSED BY is issued, I shall not employ any person in any manners s to I BOILER BTU become subject to the Workers'Compensatio Laws. Ode COMPRESSOR,BTU Date Z ?- Applicant w VENTILATION SYSTEM APPROVALS DATE INSPECTOR'S SIGNATURE NOTICE TOA PLICANT: If, after makin It is Certificate of ROUGH Exemption,you should become subject to the W kers'Compensation EVAPORATIVE COOLER FINAL provisions of the Labor Code,you must forthwith comply with such _ provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATION I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED—UNIT— (commencing USPENDED UNIT(commencing with Section 7000)of Division 3 of the Business and WALL Professions Code,and my license is in full force and effect. r1 F�4T.s JJ0 License Number (c'.oSI�� LID.Class ' h al'i{{ � Jr c / ��t. 9 Contractor ` � �+Date �Z 1 ITEMS, C ❑ I am exempt under sec. Plan check fee TOTAL 32.4 1 C BAP.C.for this reason PERMIT ISSUING FEE$ !� ��r CHECK 32.41 C Oil L Date: TOTAL FEE �, J CHANGE . 11 Signature PLAN CHECK APPLICANT V OWNER-BUILDER DECLARATION 11000-13001 12/18/923 1 hereby affirm that I am exempt from the Contractor's License Law NAMEt r for the following reason(Section 7031.5, Business and Professions '4�3�7` � �- Poo. 714•? 1 AM 8:40 Code): ADDRESS ❑ I, as owner of the property, or my employees with wages '�"`�i� C,.Q" as their sole compensation, will do the work and the CITY 'D TEL.NO. structure is not intended or offered for sale(Section 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 1C2_7_4 tion 7044,Business and Professions Code). CIT1�� /•� TEL.NO. CONSTRUCTION LENDING AGENCY P � C-w-4 I hereby affirm that there is a construction lending agency for CONTRACTOR , the performance of the work for which this permit Is issued s (Sec.3097,Civ.C.). ADDRESS Lender's Name CITY TEL.NO.'7��'� G � Lender's Address STATE LIC. I certify that I have read this application and state that the above LICENSE NO. Q Z- CLASS X,- information is correct. I agree to comply with all County ordinances and State laws relating to building construction,and hereby authorize representativ of this County nter upon the above-mentioned Property f 1 spect' pur es. SEE REVERSE FOR EXPLANATORY LANGUAGE SI6 TUR.0 F P NT OR AGENT DAT WORKERS'COMPENSATION DECLARATION I„hevsky'dffirm that I have a certificate of consent to self ! APPLICATION FOR PERMIT insure, or a,cgrC%f;1gp of Workers'Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING r tified ropy the sof(Sec. 3800, Lab. C.) � 76A 818 G CE-818(REV. 10/81) Poli No.1 Company P/1/ke 4f ❑ Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY Certified copy is filed with the county building insp - FOR APPLICANT TO FILL IN BUILDING ` tion de tment. (PRINT OR TYPE ONLY) ADDRESS G /UCeGJ! C Date � Applicant LOCALITY NO. TYPE OF APPLIANCE OR EQUIPMENT FEE L CERTIFICATE OF EXEMPTION FROM WORKERS' CNEARE ROSS 87. l/`�C/�IvZ�nl COMPENSATION INSURANCE (This section need not be completed if the work involved by ABSORPTION UNIT,BTU Jele-1 T NO. PROCESSED BY 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 permit is issued,I shall not employ any person in any manner BOILER,BTU so as to become subject to the Workers'Compensation Laws. APPROVALS DATE INSP CTOR'S SIGNAT E Date Applicant f COMPRESSOR, BTU J� 0H Jlf b X NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER T-CW with comply with such provisions or this permit shall be deemed revoked. FLOOR FURNACE: FAU BTU GRAVITY LICENSED CONTRACTORS DECLARATION 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 WALL and Professions Code,and my license is in full force and effect. 0. 7 5� u License Number ��'✓ Lic. Class , IM p C°ai✓�a� 01–d-��' 29790A o Contractor N Date ❑ U Im 0 aexempt under Sec. # 0 0 0 0 8 a Plan check fee B.BP.C. for this reason PERMIT ISSUING FEE $ 0 ( ° - 3 G5 0 Date: r� Signature TOTAL FEE ° 3 Q 5 0 6 OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT 0606 -88 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): ❑ 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). IL A OWNER T ❑ I, as owner of the property, am exclusively contracting �/� / with licensed contractors to construct the project (Sec- ADDRESS /vGe GtJ%�C/ 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 7`r CITY �� `d�'f TEL. NO. —A Lender's Address STATE LIC U . I certify that I have read this application and state that the LICENSE NO. 3,?3Y CLASS 5Ca v d 3f 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 upo - :;�bove-mentioneerty for inspectin purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent �j/ G,�YjDa-tee�U�7