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Home My Public Portal About5505 RYLAND AVE_Mechanical__ WORKER'S COMPENSATION DECLARATION 2 640 PW 9189 APPLICATION FOR PER MITLIME GREEN. I heresy affirm that I have a certificate of consent to self Insure, �} or a certificate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING ry1L11� 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. ❑ Certified copy is filed with the count building inspection FOR APPLICANT TO FILL IN BUILDING e— ,- department. y p (PRINT C TYPE ONLY) ADDRESS.D�d /1(/— ) LT/N 11 ' LOCALI �M Date Applicant PLG' �r NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' NEARESST.T al L �• COMPENSATION INSURANCE CROSS OR ABSORPTION UNIT,BTU ASSESSOR (This section need not be completed if the work Involved by the MAP BOOK PAGE PARCEL permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO. PROCESSED BY I certify that In the performance of the work for which this permit is issued, I shall not employ any person In any manner so as to I BOILER,BTU become subject to the Workers'Compensation Laws. I COMPRESSOR,BTU APPROVALS DATE INSPECTOR'S SIGNATURE Date Applicant VENTILATION SYSTEM NOTICE TO APPLICANT: If, after making this Certificate of ROUGH Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER provisions of the Labor Code, you must forthwith comply with such FINAL Q_ provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATION I hereby affirm that I am licensed under provisions of Chapter 9 I / HEATER: SUSPENDED UNIT i (commencing with Section 7000) of Division 3 of the Business and WALL Professions Code,and my license is in full force and effect. a �•-i7- f License Number Lic.Class 5303 • .+-a ri l` } Contractor Date L; F1 Plan check fee TC I T NL 52-05 I am exempt under Sec. { C �,- CHECK :��a(JC C B.&P.C.for this reason PERMIT ISSUING FEE$ 4 () __ C Date: TOTAL FEE �•�Iti�`j��E: �fir. LL a?= � a Signature PLAN CHECK APPLICANT OWNER-BUILDER DECLARATION 03001-010,131 10/22/9,_' 32 1 hereby affirm that I am exempt from the Contractor's License Law NAME for the following reason(Section 7031.5, Business and Professions , +=t•`J 5 H� ?°-`/ Code): e): ADDRESS I, as owner of the property, or my employees with wages as their sole compensation, will do the work and the CITY TEL.NO. structure is not Intended or offered for sale(Section 7044, Business and Professions Code). 10 odWNE — fl9JI I, as owner of the property, am exclusively contracting MAIL ' with licensed contractors to construct the project (Sec- ADDRESS 560.15 tion 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY CI % �`� TEL.NO.,2,Wb 1 I hereby affirm that there is a construction lending agency for CONTRACTOR , the performance of the work for which this permit Is issued (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 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 representatives of th' unty to enter upon the above-mentioned operty for inspe to urposes. f O ls:z-)q SEE REVERSE FOR EXPLANATORY LANGUAGE IcItrUl 3 SIGNATURE OF APPLICANTCR AGENT DTE - I WORKER'S I have a certiIONficate of consent to 2010048 DPW APPLICATION FOR PERMIT LIME GREEN 76j1364C I hereby affirm that I have a certificate of consent to self insure, or a certifidate of Worker's Compensation Insurance, or a certified � HEATING-VENTILATING-AIR CONDITIONING i`.opy thereof(Sec.3800 Lab.C.) Policy No. Company I COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV. Certified copy is hereby furnished. ❑ Certified copy is filed with the count buildingIns ection FOR APPLICANT TO FILL IN BUILDING �� h y� department. y P (PRINT OR TYPE ONLY) ADDRESS K lJ Date Applicant LOCALITY 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 MAP OOK 0 PAGE 491A PARCELb?,2,460 permit Is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO. PROCESSED BY I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to BOILER,BTU i become subject to the Workers'Compensation Laws. p .Q� / 1 COMPRESSOR,BTU -0 8 Date A IlCent t APPROVALS DATE INSPECTOR IGNATURE PP VENTILATION SYSTEM ' S NOTICE O AP LICANT: If, afte eking this Certificate of ROUGH - Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER / provisions of the Labor Code, you must forthwith comply with such OE FINAL 6 provisions or this permit shall be deemed revoked. r FURNACE: FAU RA TY �S VALIDATI N LICENSED CONTRACTORS DECLARATION ( FLOOR BTU Zin I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT (commencing with Section 7000)of Division 3 of the Business and WALL 11 Professions Code,and my license is in full force and effect. D License Number 9 -S J g Lic.Class C' , L- C Contractor Date V // C ❑ Plan check fee ANT o 4 I am exempt under Sec. 33'f j! 85.K e B.& P.C.for this reason PERMIT ISSUING FEE$ )- Date: TOTAL FEE ��Q ` TENS LL Signature TOTAL .23"5 a go Cr OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT CHECK i._s-.1-Cr_ ,= I hereby affirm that I am exempt from the Contractor's License Law NAME 010. f CHANGE for the following reason(Section 7031.5, Business and Professions =. NGE Code): ADDRESS ❑ I, as owner of the property, or my employees with wages as their sole compensation, will do the work and the CITY TEL.NO. 01,1100-13001 6/14/9"j structure is not intended or offered for sale(Section 7044, ,t ,.��i Business and Professions Code). OWNER 5657 1 AI 111° ❑ I, as owner of the property, am exclusively contracting MAIL with licensed contractors to construct the project (Sec- ADDRESS tion 7044,Business and Professions Code). CITY TEL.NO. CONSTRUCTION LENDING AGENCY I thereby affirm that there is a construction lending agency for CONTRACTOR , I he performance of the work for which this permit Is issued (--�AJ D CD4S' � C6la P (Sec.3097,Civ.C.). 1 ADDRESS 3 _ M *�( u.&2 CA 9-1 Lender's Name CITY L—A , TEL.NO.2,('3 Z Z 1 Lender's Address I certify that I have read this application and state that the above LICENSE NO. s, -10 0 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 the above-mentioned property for ins ction purpose;. SEE REVERSE FOR EXPLANATORY LANGUAGE SIGNATURF13F APPLICANT OR AGENT DA E