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Home My Public Portal About5741 ROWLAND AVE_Mechanical__ MPENSATION DECLARATION ( 76A364C I herer�v affirm„4nat I have a certificate of consent to self I CE -818 (2-80) APPLICATION P®R PERMIT insure,,nr_?Corti. Cate of Workers'Compensation Insurance,or HEATING-VENTILATING-AIR CONDITIONING a dertifieti i:olif thereof(Sec.3800,Lab.C.) ) PolicyCompan Certified copy is hereby furnished.y COUNTY OF LOS ANGELES BUILDING AND SAFETY � , Certified copy is filed with the county building inspection I - APPLICANT TO FILL IN BUILDING �. department. I FOR Date Applicant (PRINT OR TYPE ONLY) ADDRESS LOCALITY` CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE COMPENSATION INSURANCE NEAREST } (This section need not be completed if the work involved I ABSORPTION UNIT, BTU CROSS ST. 0 ' O by the permit is for one hundred dollars (S100) or less.) DISTRICT NO. P Ess BY U I 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 `J OO so as to become subject to th Yorkers'Comp nsatfon Laws. BOILER, BTU APPROVALS DATE IN P TOR'S SIGNATURE IU Date-&-2-A& Applicant COMPRESSOR,BTU ROUGH N NOTICE O APPLiCAN . f, after making this Ce icate of VENTILATION SYSTEM FINAL ��i G� z Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- I EVAPORATIVE COOLER VALID ION with comply with such provisions or this permit shall be deemed revoked. I FURNACE: FAU GRAVITY /) r LICENSED CONTRACTORS DECLARATION FLOOR BTU !1 I hereby affirm that I am licensed under provisions of Chapter HEATER: SUSPENDED UNIT 9 (commencing with Section 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 FII 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 $ 110 15z Lic,or Reg.No. Date TOTAL FEE a2C� HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT I I hereby affirm that I am exempt from- the Contractor's NAME. License Law for the following reason (Section 7031.5, Busi- ness 'd Professions Code): ADDRESS t as owner of the property, will do the work and the structure is not intended or offered for sale (Section CITY TEL.NO. 7044, Business and Professions Code). El 1, i, as owner of the property, am exclusively contracting 2543. 1 A with licensed contractors to construct the project MAIL ' (Section 7044, Business and Professions Code). ADDRESS # e o o e o 8 CONSTRUCTION LENDING AGENCY CITY TEL.NO. I o o 2 Q 5 0 I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is CONTRACTOR e o - 2Q506 issued (Sec. 3097,Civ.C.). Lender's Name ADDRESS 09128 Lender's Address CITY TEL.NO. I certify that I have read this application and state that the STATE LIC. above information is correct.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 C.Anty to enter upon the above-mentioned property for I pection purposes. li ignature o Per tttee Date I WORKER'S COMPENSATION DECLARATION II7SM(ft DPW 9/89 APPLICATION FOR PERMIT `IME GREEN I hpreb�affirm that I have a certificate of consent to self insure, 76A364C or a cattificate 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. ❑ UILDING Certified Copy is filed with the county building Inspection FOR APPLICANT TO FILL IN ADDRESS o P N department. (PRINT OR TYPE ONLY) Date Applicant LOCALITY "f" NO. TYPE OF APPLIANCE OR EQUIPMENT FEE /n� l P A , n '�( �` ,�{ n EST CERTIFICATE OF EXEMPTION FROM WORKERS' CRONEASS ST. L-(1 v L O( �\ r w o R K rel, ,v COMPENSATION INSURANCE ABSORPTION UNIT,BTU (This section need not be completed if the work involved by the MAP BOOK PAGE PARCEL permit Is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO. PROCESSED BY I certify that In the performance of the work for which this permit Is Issued, I shall not employ any person in any manner so as to BOILER,BTU y. become subject to the Workers'Compensation Laws. I stow (/ COMPRESSOR,BTU APPROVALS DATE INSPECTOR'S SIGNATURE Date Applicant VENTILATION SYSTEM NOTICE TO APPLICANT: If, after making this Certificate of ROUGH _2." Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER provisions of the Labor Code,you must forthwith comply with such FINAL Z provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATION I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED • UNIT (commencing with Section 7000)of Division 3 of the Business and HEATER: WALL Professions Code,and my license is in full force and effect. License Number LID.Class I ' Contractor Date , C ❑ I am exempt under Sec. Plan Check fee C B.&P.C.for this reason PERMIT ISSUING FEE$ Date: TOTAL FEE G Signature V OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT C 1 hereby affirm that I am exempt from the Contractor's License Law NAME for the following reason(Section 7031.5, Business and Professions _ od : ADDRESS I, as owner of the property, or my employees with wages -y is o l-I'. as their sole compensation, will do the work and the CITY TEL.NO. structure is not intended or offered for sale(Section 7044, s Business and Professions Code). OWNER ❑ - I HL m5 m 00 I, as owner of the property, am exclusively contracting MAIL r^ I I with licensed contractors to construct the project (Sec- ADDRESS CITY TEL.NO.J I r•r.: H r , tion 7044,Business and Professions Code). n_ t/ �'�S'� CONSTRUCTION LENDING AGENCY ( 7 l Ey"H,ANGE: Ihereby affirm that there is a construction lending agency for ACTOR— , the performance of the work for which this permit CONTRACTOR— the Is issued — (Sec.3097,Civ.C.). ADDRESS DO 61271ty'; Lender's NameA a ! CITY TEL.NO. —17 64 i Ail,-•I0'4 U'E 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 t representatives of this County to enter upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE SIG T E OF APPL OR AGENT — DATE