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Home My Public Portal About6123 RENO AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT `:.I hereby affirrq that fhave•a certificate of corisent to self insure, or a certificate of Workers' Compensation.l9syurance,,.;; 76A364c HEATING - VENTILATING - AIR CONDITIONING ora,certified copy thereof (Sec. 3800, Lab'C..) 20-0046 DPW 9AB Policy Nb. Company ❑ Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY F] 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 �rz COMPENSATION INSURANCE CROSS ST. (This section need not be completed if the work involved by ABSORPTION UNIT, BTU ]] (� DISTRICT NO. PROCE D BY the permit is for one hundred dollars (;100)or less.) AIR HANDLING UNIT, CFM Af 6� O V X }{- 1 certify that in the performance of the work for which this �s D(J yJ 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 DATES ECT R'S SIGN TURE Date Applicant COMPRESSOR, BTU , 4 ®�/ ROUGH ] r' 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 VALI ATIO withcomp with such provisions or this permit shall be deem- ed 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 WALL. and Professions Code,and my license is in full force and effect. p� } License Number Lic. Class , 0 u Contractor Date' ❑ 1 am exempt under Sec. O Plan check fee u W B.BP.C. for this reason _ Date: PERMIT ISSUING FEE $ 1.3100 Z TOTAL FEE 100 Signature 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 3307 61.00 Pro essions Code): I, as owner of the property, or my employees with ADDRESS ITEMS wages as their sole compensation,will do the work and CITY TEL. NO. TOTAL 6 1®01131 the structure is not intended or offered for sale(Section 7044, Business and Professions Code). OWNER `+ i�(T�A (HECK 01.011 ❑ (/� 1 3 // I, as ownet of the property, am exclusively contracting �s, with licensed contractors to construct the project (Sec- AMAILDDRESS /r� CHANGE .0 0 tion 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY CITY �Q%�. t��j'. Cic�. TEL. NO. I hereby affirm that there is a construction lending agency for 00. 5/21/911 the performance of the work for which this permit is issued CONTRACTOR (Sec. 3097, Civ. C.). 0205• 1 AM 9 8 ADDRESS , Lender's Name CITY TEL.NO. Lender's Address I certify that I have read this application and state that the STATE LICENSE NO. CLLASS 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 the above-mentioned property for inspection purposes: SEE REVERSE FOR EXPLANATORY LANGUAGE \ \ - -�- gnat a of Applicant or Agent Date ION WORKER'S I have a certificate of consent to 766M64C DPW 9/89 APPLICATION FOR PERMIT LIME GREEN: - I hereby affirm that I have a certificate of consent to self insure, or certificate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING copy thrreof(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 ADDRESS department. (PRINT OR TYPE ONLY) Date ApplicantLOCALITY NO. TYPE OF APPLIANCE OR EQUIPMENT FEE NEARESTLa . //J�a'�✓S CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST. N ry COMPENSATION INSURANCE ABSORPTION UNIT,BTU (This section need not be completed if the work Involved by the MAP BOOK J J permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM MAP BOOK J f PACE SED By PARCEL O 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 manner so as to BOILER,BTU ,D� become subject to the Workers'Compensation Laws. COMPRESSOR,BTU APPROVALS DATE INSPECTOR'S SIGNATURE Date Applicant VENTILATION SYSTEM NOTICE TO APPLICANT: If, after making this Certificate of ROUGH Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER provisions of the Labor Code, you must forthwith comply with such FINAL 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. License Number Lic.Class } a Contractor Date CF1 ' I am exempt under Sec. Plan check fee B.&P.C.for this reason PERMIT ISSUING FEE + C Date: TOTAL FEE _5 ACCT e 4 C Signature 37407 f'a-' a PLAN CHECK APPLICANT a OWNER-BUILDER DECLARATION i ITEMS 1 hereby affirm that I am exempt from the Contractor's License Law NAME �►�,� 1 � K ,,-� for`.the following reason (Section 7031.5, Business and Professions Pool, TOTAL 29.55 LJ e): 1, 4�+ Cc I, as owner of the property, or my employees with wages ADDRESS � � a�b CHECK as their sole compensation, will do the work and the CITY V3_ GG' TEL.NO. ,�'�a. ��,�� ,(_IO structure is not intended or offered for sale (Section 7044, Business and Professions Code). OWNER /i,� ❑ I, as owner of the property, am exclusively contracting n�y�1t��`` �iS1r�i ! with licensed contractors to construct the project (Sec- ADDRESS 0000-0001 i y 213Jf 117, tion 7044,Business and Professions Code). CITY TEL.NO. 9334 1 Ai t 3:IJv CONSTRUCTION LENDING AGENCY hereby affirm that there is.a construction lending agency for CONTRACTOR , the performance of the work for which this permit Is issuedIwA (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 above LICENSE NO. CLASS 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 the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE SI6NA E OF APPLICANT OR AGENT DATE