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Home My Public Portal About5741 RIO HONDO AVE_Mechanical__ �'• ,r".-a*W6kKERS"i!OMPENSATJON DECLARATION / APPLICATION FOR PERMIT I hent,. affirm That I have a cer'fificote of consent to self iflsure,'or o.certificate of Workers'Compensation Insurrance, , HEATING - VENTILATING - AIR CONDITIONING or a cerlified copy thereof (Sec. 3800, Lob. C.) 10 76A364C CE-818(REV. 10/81) Policy Pip.—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 i tion department. (PRINT OR TYPE ONLY) ADDRESS 514\ `' ZkO Date Applicant A LOCALITY -Mf QLZ CA-6NO. TYPE OF APPLIANCE OR EQUIPMENT FEE uv 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 SED the 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 is issued, I shall not employ any person in any manner BOILERBTU so as to become subject to the Workers'Compensation LOWS. , 42-000 �J / APPROVALS DATE IN PE•OR'S SIGNAT E S� l COMPRESSOR, BTU 1 -00 0 I 0O ROUGH Date Appl ican��—�� 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 V LI A I with comply with such provisions or this permit shall be / deemed revoked. FURNACE: FAU GRA I Y LICENSED CONTRACTORS DECLARATION FLOOR BTU -7 00 IO 10()— 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. IL O License Number Lic. Class � 1038A af Contractor Date � o 0 0 0 0 8 I a - 30,50 11— ❑ I am exempt under Sec. y 2 Plan check fee a ° a �3 C 0 IL B.BP.C. for this reason U) PERMIT ISSUING FEE $ �G 1 1 01 8 8 Date TOTAL FEE 30 Signature OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT I hereby affirm that I am exempt from the Contractor's License ��y Law for the following reason (Section 7031.5, Business and NAME �F�tr �k&AN 10. ro ssions Code): NJ ;K,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 `-MKk0\,Fc` TEL. NO.2oo-1 7044, Business and Professions Code). � � �` _/t OWNER , , 9 � ❑ I, as owner of the property, am exclusively contracting MAIL ( with licensed contractors to construct the project (Sec- ADDRESS ` V I\� tion 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY CITY -k-r_ 0 kS_ C_A-V-�TEL. NO. 2(W•-'ICA.(o 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 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 upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent Date DEC N()1affirm that 1:ve a, certificate ficate .of consent CEA 818 C(2-80) #Aa P P UC ATA O N FOR P I�(�fl�ll 0 lT I hereh'� affirm that [ Have a' curtificute of consent to self insure, e a certificate nl(Sec. 380 C:a b.C.) tion Insurance,or HEATING-VENTILATING-AIR CONDITIONING certified ropy thereof(Sec. 3800,Lab.C.) Policy Company — Certified copy is hereby furnished. COUNTY OF LOS ANGELES / BUILDING ARID SAFETY Certified copy is filed with the county building inspection BUILDING department. FOR APPLICANT TO FILL IN Date Applicant (PRINT OR TYPE ONLY) ADDRESS U ,. CLRTIFICATE 01• EXEMPTION I'ROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY 1110EMILf Uri COMPENSATION INSURANCE NEAREST � �� CROSS.S � T. C k >_(This section need not be completed if the work involved ABSORPTION UNIT, BTU CL by the permit is for one hundred dollars ($100) or less.) DISTRICT NO. PROCES D BY U 1 certify that in the performance of the work for which this AIR HANDLING UNIT,CFM permit is issued, I shall not employ any person in any manner C (�( �� tr so as to become subject to the Workers'Compensation Laws. BOILER,BTU D5.00d .2 O APPROVALS DATE INSPECTOR'S SIGNATURE V Date Applicant COMPRESSOR,BTUW ROUGHp- NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM N Exemption, you should become subject to the Workers' FINAL Z Compensation provision% of the Labor Code, you must forth- with comply with such provisions or this permit shall be EVAPORATIVE COOLER VALIDATION deemed resoked. FURNACE: FAU GRAVITY LICENSED CONTRACTORS DECLARATION FLOOR: BTU 1 hereby affirm that I am licensed under provisions of Chapter HEATER: SUSPENDED UNIT 9 (commencing with Srction 7000)of Division:3 of the Busi- WALL ness and Professions Code, and my license is in full force and effect. License Number Lic.Class Contractor Date I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer Plan check fee 25%of above. acting in my professional capacity (Section 7051, Bus- iness and Professions Code). PERMIT ISSUING FEE$ J�} Lie.or Reg.No._ nate TOTAL FEE 13-356 HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT I hereby affirm that I am exempt from the Contractor's NAME License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): ADDRESS I 1, as owner of tite property, will do the work and the Structure is not intended or offered for sale (Section CITY TEL. NO. 7044, Business and Professions Code). nEl 3$ 2 A OWNER {�/�`1/ `J�/� I, as awns[ of the property, am exclusively contracting ,_ "i••ll�, "_` l�(��qq ,l with licensed contractors to construdt the project AMAILDDRESS rJ��l N,�C� WII iO v 4 ° ° ° ° ° 8 (Section 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY CITY pkSC,� TEL.NO 2 ° ° 3 3 5 0 1 hereby affirm that there is a construction lending agency CONTRACTOR °�° ° 7J 0 for the performance of the work for which this permit is issued (Sec. 3097,Civ.C.). Lender's Name 11 ADDRESS () 4 3 0-8 2 Lender's Address CITY TEL.NO. I certify that 1 have read this application and state that the STATE LIC. above information is LOrrect.I agree to comply with all County LICENSE NO. CLASS ordinances and State laws regulating Heating. Ventilating and Air Conditioning. and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE County to enter upon the above-inentioned property for inspection purposes. ��j^/rf]//��J—/' \� g4Io/ Signature of Permittee Date