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Home My Public Portal About5730 RIO HONDO AVE_Mechanical__ ION WORKER'S I have a CeSATate of consent to 20.0046DPW 9/89 APPLpCARTION FOR PERMIT L�AAE GREEN 76A384C I henSoy affirm that I have a certificate of consent to self Insure, or W.ertiticate 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. ❑ FOR APPLICANT TO FILL IN BUILDING 01 Certified copy is filed with the county building Inspection department. (PRINT OR TYPE ONLY) ADDRESS Q Date Applicant LOCALI NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST CROSS ST. COMPENSATION INSURANCE ABSORPTION UNIT,BTU This section need not be completed If the work Involved by the ASSESSOR ( P i MAP BOOK PAGE PARCEL permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO. PROCESS D 9Y I certify that in the performance of the work for which this permit is Issued, I shall not employ any person in any manner so as to ' BOILER,BTU ijl become subject to the Workers'Compensation Laws. (// COMPRESSOR,BTU APPROVALS DATE INSPECTOR'S SIGNATURE Date Applicant VENTILATION SYSTEM NOTICE TO APPLICANT: If, after making this Certificate of ROUGH Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER / ra provisions of the Labor Code,you must forthwith comply with such FINAL SID provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATION I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT (commencing with Section 7000)of Division 3 of the Business and ® HEATER: WALLy �� Professions Code,and my license is In full force and effect. License Number Lic.Class Contractor Date A CT,a Q ❑ I am exempt under Sec. Plan Check fee 3303 50.5-t V BAP.C.for this reason PERMIT ISSUING FEE$ 1 I T w Date: TOTAL FEET TOT A fL U f+V 2 0 � o � Signature PLAN CHECK APPLICANT CHECK a `� OWNER-BUILDER DECLARATION t t •1 I hereby affirm that I am exempt from the Contractor's License Law NAME , CHANGE ,I!I_ for the following reason(Section 7031.5, Business and Professions Cods): ADDRESS I, as owner of the property, or my employees with wagesL�GLI_t10�11 +� 4 as their sole compensation, will do the work and the CITY TEL.NO. 6/21/4 structure is not intended or offered for sale(Section 7044, 11371 1 83 Business and Professions Code). OWNER42 �f117�1u ❑ 1, as owner of the property, am exclusively contracting MAIL with licensed contractors to construct the project (Sec- ADDRESS V tion 7044,Business and Professions Code). h CONSTRUCTION LENDING AGENCY rO ITY TEL.NO. dbb I hereby affirm that there is a construction lending agency for NTRACTOR , the performance of the work for which this permit Is issued (Sec.3097,Civ.C.). ADDRESS Lender's Name [STATE Y TEL.NO. Lender's Address LIC. I certify that I have read this application and state that the above ENSE 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 theabove-mentioned / property for inspectioWur a., 6 1 9 SEE REVERSE FOR EXPLANATORY LANGUAGE SIGNAT E OF APPLICANT OR AGENT DATE , —t."V70RKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT 1,hereby affirm con that I hav* a certificate of sent to self. insure, or a certificate of Workers'Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING or a certified copy thereof(Sec. 3800, 1%. C.) 76A364C 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 inspec- FOR APPLICANT TO FILL IN BUILDING tion department. ADDRESS C j® /� CQ (PRINT OR TYPE ONLY) Date Applicant I LOCALITYG f NO. TYPE OF APPLIANCE OR EQUIPMENT FEE G44 CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST COMPENSATION INSURANCE, i CROSS ST. 0 (This section-need not be completed if thework involved by ABSORPTION UNIT,BTU DISTRICT NO. PROCESJED BY the permit is for one hundred dollars(:100)or less.) , AIR HANDLING UNITCFM �` o(/ I certify that in the performance of the work for which this i , W f permit is issued, I shall not employ any p. on inoony manner so as to become subject to theXWorkero nsa' s. BOILER,BTU APPROVALS DATE J ECTOR'S SI NATURE Date V pplica COMPRESSOR,BTU ROUGH NOTICE TO APPLICANT: If, afis C rtificate of VENTILATION SYSTEM FINALExemption, you should becot to the Workers' Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VAI IDATI with comply with such -provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY LICENSED CONTRACTORS DECLARATION FLOOR BTU I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDE UNIT '(commencing with Section 7000)of Division 3 of the Business - WALL and Professions Code,and my license is in full force and effect. O License Number tic. Class , W Contractor Date ` ❑ I am exempt under Sec. us Plan check fee JL sA B.BP.C. for this reason Date: PERMIT ISSUING FEE $ Z Signature TOTAL FEE 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, Businessland NAME � � Prof cions Code): ;27523A ADDRESS �--7 2 I as owner of the property, or my employees with s �7� /� #,.o 0 0 0 0 8 wages as their sole compensation,will do the work and CITY� � G.� TEL. NO I ° ° 3 Q 5 0 the structure is not intended or offered for sale(Sectionewr 7044, Business and Professions Code). o.o 0 7j Q 5 0 C5❑ I, as owner of the property, am exclusively contracting OWNER �1e� 07,24-87 with licensed contractors to construct the project (Sec- ADDRESS 670 d6 N tion 7044, Business and Professions Code). ,CONSTRUCTION LENDING AGENCYCITY C!7 TEL. NO. I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued CONTRACTO &%eVL6V4,je d! t , (Sec. 3097, Civ. C.). ADDRESS Lender's Name CITY TEL. NO. Lender's Address. [STAE LIC..I certify that I have read,this application and state that the NSE NO. CLASS above information is correct. I agree to comply with all County ordinanc�_�_Ll ' to building construction, and heres of this County to enter upon t for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Si ature. Ap ant or Ag nt Dote o