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Home My Public Portal About6223 RENO AVE_Mechanical__ 10 `.WJRKER'SCOMPENSATION DECLARATION ntto ��PW9/89 APPLICATION FOR PERMIT LIME GREEN I hereby affirhisrat I have a certificate of consent to self Insure, or a ce'rtiyca� �o Wbrker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING copy thereof SO.3800 Lab.C.) • ' PolK No.UK 140 Company ✓tom►TC daa _ 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 1 department._c (PRINT OR TYPE ONLY) Date `/Zj 'q_s ApplicantLOCALITY NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST CROSS ST. COMPENSATION INSURANCE ABSORPTION UNIT,BTU _ OR (This section need not be completed if the work Involved by the MAP BOOK ter, �j' PAGE Oe/` PARCEL GP/'7 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 manner so as to BOILER BTU become subject to the Workers'Compensation Laws. COMPRESSOR,BTU APPROVALS DATE PECTOR'S aNATURE 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 VITY // LICENSED CONTRACTORS DECLARATION / FLOOR BTU �!v (Q VALIDATION 1 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 its in full force and effect. ' � �e^C/ License Number -351 Lic.Class L ACCT°g Contractor Date el ® 3303 109°90 Q ❑ I am exempt under Sec. Plan Check fee 1 ITEMS V B.&P.C.for this reason PERMIT ISSUING FEE p TOTAL 1101a0 te: TOTAL FEE �fQ CHECK � 109.90M54 W Sign PLAN CHECK APPLICANT CHANGE ■00 O � W CLARATION I hereby affirm that I am exempt from the Contractor's License Law NAME ( CCS �'Y e 7�7�_1 6 for the following reason (Section 7031.5, Business and Professions ' 000 - 001 11/ Code): ADDRSS F1 1. as owner of the property, or my employees with wages 1b rw a1„0w� 3245' 1 AM 937 as their sole compensation, will do the work and the CIITY t TEL.NO. 2,"S structure is not intended or offered for sale(Section 7044, G Business and Professions Code). OWNER F1I. as owner of the property, am exclusively contracting MAIL t 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 CONTRACTOR the performance of the work for which this permit Is issued I j its C (r1 (Sec.3097,Civ,C.). ADDRESS Lenders Name � �• CITYZ��c-, TEL.NO. 3 3Z -.0 `L' 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 I representatives of this County to enter upon the above-mentioned i nrooerV for Inspection r os s. SEE REVERSE FOR EXPLANATORY LANGUAGE � 14n SIGNATuRE OF APPLICANT OR AGENT �� DATEt *, AS'COMPENSATION DECLARATION I APPLICATION FOR PERMIT I hereat I havea certificate of consent to self 'inWreCate of Workers'Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING or a gthereof(Sec. 3800, Lab. C.) 76A364C CE-818(REV. 10/81) Policy No. _ Gpmpany - Certified copy is hereby furnished. COUNTY OF LOS.ANGELES BUILDING AND �SAFETY yy � ❑ Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING ADDRESS Z7/ �Z-/v0 /rlfr /` C- 7�� tion department. (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. PROLE eY the permit is for one hundred dollars(;100)or•lesii) AIR HANDLING UNIT,CFM Q I certify that in the performance of the work for which this a (% 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 INSPECTORS SIGNAtURE Date rZ pplicant COMPRESSOR,BTU ROUGH NOTICE TO APPLICANT:- If, after aking is 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 ppp 4� deemed revoked. FURNACE: FAU GRAVITY n LICENSED CONTRACTORS DECLARATION FLOOR BTU CSC ( r� tt U 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. ` License Number Lic. Class oil, U J lit Contractor Date ❑ I am exempt under Sec. d Plan check fee e.&P.C. for this reason, PERMIT ISSUING FEE$ Q Date: Signature II TOTAL FEE 12,01 gV 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 o essions Code): I, as owner of the property, or my employees with ADDRESS wages as their sole compensation,will do the work and CITY TEL. NO. the 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 :95 4 9.6 A with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code). • # 0.0'0 0 0 8 CONSTRUCTION LENDING AGENCY CITY TEL. NO. I hereby affirm that there is a construction lending agency for i o-o 2 Q 5 0 the performance of the work for which this permit is issued (Sec. 3097, Civ. C.). CONTRACTOR , • o 0 0 2 Q 5 0 0 ADDRESS 09.24-86 Lender's Name- CITY TEL. NO. Lender's Address STATE LIC. I certify that I have read this application and state that the LICENSE NO. CLASS 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 upal the above-me ioon�ed property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE SiXture of A licont or AgentDotel WORKER'S COMPENSATION hle of consent to 7W.64 DPW 9/89 APPLICATION FOR PERMIT LICE GREEN: � 76A3,f14C I hereby 441m that'l have 'd certificaRe of consent to self insure, or rsbertificate of Worker's Compensation Insurance, or a certified •• HEATING-VENTILATING-AIR CONDITIONING copy thereof(Sec.3800 Lab.C.) f Policy No. Company S�Am- 'COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV. IBG Certified copy is hereby furnished. ❑ FOR APPLICANT TO FILL IN BUILDING Certified copy is filed with the county building inspection PRINT OR TYPE ONLY) ADDRESS departsm+�ent.. ! ( YJ Date �_j _ � Applicant LOCALITY NO. TYPE OF APPLIANCE OR EQUIPMENT FEE �• / -/ CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST. COMPENSATION INSURANCE ABSORPTION UNIT,BTU ASSESSOR (This section need not be completed if the work Involved by the =PARCO" permitis for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM MAP BOOKPAGE�! DISTRICT NO. PROCESSED BY I certify that in the performance of the work for which this permit CCCC,,,,pppp Is issued, I shall not employ any person in any manner so as to BOILER,BTU �L become subject to the Workers'Compensation Laws. COMPRESSOR,BTU APPROVALS DATE INSPECTOR'S SIGNATURE Date Applicant VENTILATION SYSTEM R NOTICE TO APPLICANT: If, after making this Certificate of ROUGH Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER provisions of the Labor Code,you must forthwith comply with such FINAL provisions or this permit shall be deemed revoked. FURNACE: FAU f., GRAVITY LICENSED CONTRACTORS DECLARATION FLOOR BTU o VALIDATION I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT (commencing with Section 7000)of Division 3 of the Business and HEATER: WALL Professions Code,and my license is in full force and effect. VV eTr O (v License Number Lic.Class �� } Cc recto Date /r�7 F1 - C ❑ Plan check fee r. _•T, C: I am exempt under Sec. -- _ _a B.&P.C.for this reason PERMIT ISSUING FEE$ F- Date: TOTAL FEE Signature PLAN CHECK APPLICANT ��`( � `"~U, OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law NAME w LG�� for the following reason (Section 7031.5, Business and Professions poll- Code): Code): ADDRESS `1L 0� I ❑ I, as owner of the property, or my employees with wages !T as their sole compensation, will do the work and the CITY .OF TEL.NO. �,. t *_;- _; yf• : ::' structure is not intended or offered for sale(Section 7044, Business and Professions Code). G OWNER ❑ I, as owner of the property, am exclusively contracting MAIL �j s with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code). I CONSTRUCTION LENDING AGENCY CITY Z_,5 &1jTEL.NO. JO?9F11 I hereby affirm that there is a construction lending agency for the performance of the work for which this permit s issued CONTRACTOR ♦� �� (Sec.3097,Civ.C.). L ADDRESS Lender's Name CITY• �f C EL.NO. Lender's Address I certify that I have read this application and state that the above LICENSENO. Z7 CLCASS 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 ant r pon the above-mentioned pr9wrty for inspectio purp as. SEE REVERSE FOR EXPLANATORY LANGUAGE 7— WGIIIIATV OF A CA RAG DATE