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Home My Public Portal About5434 ROBINHOOD AVE_Mechanical__ T WORKER'SCOMPI7NSATK?tNDECLJIRATION -, ° s/� APPLICATION FOR PERMIT LIME GREED I hereby affirm that I have a oertifloate of consent t6 self Insure, or a cerdfloate of Worker's Compensatlon.insurance, or a oertlfled HEATING-VENTILATING SNR OONDITIONING f 13800 Lab C.) COUNTY OF LOS ANGELES DEPT OF PUBLIC WORK$ BUILDING AND SAFETY DIV. ❑ CerdfW cWy Is hereby furnished. FOR APPLICANT TO FILL IN ADDRESADDRESS Ceriffletl.00py b Wwith the county bulking (PRINT OR TYPE ONLY) LOCALITY Date / ! LocALm Appbant NO. TYPt=OF APPLIANCE OR EOXfIPitlENT FEE NEAREST CERTIRCATE OF EXEMPTK N FF*M WORMS' CF0088 ST. COMPENSATION INSURANCE ABsoRpTipN UNIT Bl'U MW section n"d not be completed If the work Involved by the MAP) PACE PARCEL permlt is for one hundred dollars({TOO)or leen) ,UR HANDLING NG UNIT CFII DIeITICT MO. PFiOCmB®aY I oertlfy 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- BTU r become subject to the Workers'Compensatlon Laws. a;p' " COM BTU ,wQriwKe oAn sepcTare sawnrra Data AP~ VENTILATION SYSTEM NOTICE TO APPLICANT: If, after making this Certificate of ROUGH ExEtmptkm,you should become subject to the Wgrken'Compernaibh EVAPORATIVE COOLM FRNAL provlslone of the Labor Code, you must forthwith comply with such provielons or this permit shall be deemed revokdd. FURNAC- FAURAyrr1� ucENSM C NTRACTOria,wro s DEATN l FLOOR BTU "tC% V 11 illiiT'n- N I hereby affirm that I am licensed under provisions of Chapter G SUSPENDED UNIT (commencing with $action 7000) of Division 3 o1 the Business and FEATEFt W Profeesiona Code,and my.ilcense Is In full force and effect Lkwoo Number Lic. Contractor Data ❑ I am exempt under se . Plan check foe sec. Plan B.tiP,C.for thio reason PERMIT ISSUING FEE= ep Dote. TOTAL FEE O p. W Slgrathre OWNER-BUILDER DECLAFlA"FlON PLAN CH� T co I hereby aNtrm that I am exempt from the Contractor's Lloense Law NAME , u for the following reason (Sectlon 7031.8, Buslness and Professions I .A Code): A9�$ L8 1 ❑ I, as owner of.the property, or my employees with wages as their solo compensation, will do the work and the CITY TEL NO. 7T[�C structure Is not Intended or offered for sale (Seotlon 7044, i ITEMS Business end Profeeabna Code). ow iER T r ❑ I, as owner of the property, am exclusively contracting MALI �111�� —' �� with licensed contractors to construct the project (Sec- ADDFIESS tion 7044, Business and Profe"lons Code). CONSTRUCTION LENDING AGENCY CITY TEL- L l�] I hereby affirm that there Is.a construction lending agency for CONTRACTOR , I performnnoe of the work for which this permit le Issued PAAAAA 1k IA (Sec.3097,CN.C.). ADDRESS CIO Lk-CICd1 i 9/1 0 91 Lenders dame ary TFi No. 02 0 - .1 Ah 9 L.endeYs Address STATE Llc. I certify that I have read this appllcadon and state that the above LICENSE NO. CLASS fnformafi)n Is correcL I agree to compty wfth an County ordinances and State laws raWing to bulkiing construction,and hereby auti•artw reprosentgtves of thla County to ante}upon t e above-mentioned pr r Ion purposes. SEE FEl/I�ME FOR EXPLANATORY LANOUAQE DEC WORKERS'COMPENSATION cafe of c'onse APPLICATION FOR PERMIT I hereby affirm That I have a certificate of consent to self Insure, or a certificate of Workers' Comperdsatron Insurance, HEATING - VENTILATING AIR CONDITIONING or a certified copy thereof (Sec. 3800, Lab. C.) 76A • CE-'818(REV.'10!81) Policy No, Company Certified copy Is.hereby furnithed. COUNTY OF LOS ANGELES T F BUILDING AND SAFETY ElCertified copy Is,filed with the county building Inspec- FOR APPLICANT TO FILL IN BUILDING tion department. (PRINT OR TYPE ONLY Date Applicant LCCA TY NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' N // COMPENSATION INSURANCE CROSS ST. !f fCior'l'✓ `� 0 k/e (This,section need not be completed tf the work Involved by ABSORPTION UNIT, BTU DISTRICT No. PROCESSM B the permit Is for one hundred dollars (;100)o4-leu.) I certify that In the performance of the work for which thle AIR HANDLING UNIT,CFM S r Q r � permit Is Issued, I shall not employ any rson in any manner V r so as to become subject to the Workers Compensation Laws. BOILER, BTU �PPROvus DATE sZPECTOR'S SK;NATUIe Data `� 3 10-1 Appllcanl-r �, BTU ROUGH NOTICE TO APPLICANT: Ff, 'Ar making this Certificate of VENTILATION SYSTEM FINAL Exemptlon, you should become subject to the- Workers' Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER AL AT with comply with such provisions or,this permit-shall be deemed revoked. FURNACE: FAU GRAVITY LICENSED CONTRACTORS.DECLARATION FLOOR BTU I thereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSairNDED UNIT '(commencing with Section 7000) of Division 3.of the-Business WALL and Professions Code,and my license Is in full force and effect. d O License Number Llc. Class U Contractor Date O ❑ I am exempt under Sec- Plan check fee BAP.C. for this reason' z - PERMIT ISSUING FEE ; /O .S z Date• Signature ti �¢�s+-s-ydo✓` TOTAL FEE 62 Q S 6 OWNER-BUILDER DECLARATION PLAN C HEO<APPLICANT 4 2.6 9.8 A I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Duslnew arid NAME #�oio:o 0 0 8 Professions Code): 2 2 Q 5.0 ❑ I, as owner of the property, or my employees with ADDREM wagers-as their sole compensation,will do the work andCITY T`EI_ tJ0 o,o"1 20,505 the structure Is not Intended or offered for sale(Section 7044, Business and Professions Code). ' owNeR3,-8'4 El 'I, as owner of the property, am exclusively contraciing . with licensed contractors to construct the project (Sec- MAIL tlon 7044, Business and Professlons Code). CONSTRUCTION LENDING AGENCY qTy TEL 110. I hereby affirm that there Is a construction lending agency for , the perfoirmance of the work for which this permit Is Issued TRACTOR (Sec. 3097, CIv.-( ). . - ADDRESS Lenders Name CITY TEL. NO. Lender's Address STATE - LIC. I certify that I have read this application and state that the LIC875f 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 �/3 Signature of Applicant or Agent De» - - -