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Home My Public Portal About5545-5545 1/2 SANTA ANITA AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION k-3 —3/ APPLICATION FOR PERMIT I hereE yjaffi•rm that I have a certtificate of consent to self •insure, or a certificate of Workers'Compensation InsOrance, . HEATING - VENTILATING - AIR CONDITIONING gr•a cert copy thereof(Sec. 3800 b.b - CE 76A364C , CE-818(REV. 10/81) .Policy NO. Compan 4U Certified copy is hereby fyrnish.ed., COUNTY-OF LOS ANGELES BUILDING AND SAFETY Certified copy is filed with the county buil Ing inspec- FOR APPLICANT TO FILL IN BUILDING tion department. ADDRESS O _nn (PRINT OR TYPE ONLY) t Date,lQY�^ P� Applicant [!Y LOCALITY NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM ERS' NEAREST COMPENSATION INSURANCE CROSS'ST. (This section need not be completed If the work involved by ABSORPTION UNIT, BTU DISTRICT NO. PROCESSED BY 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 O permit is issued, I shall not employ any person in any manner BOILER, BTU • so as to become subject to the Workers'Compensation Laws. APPROVALS DATE INSP TOR'S SIGNATURE COMPRESSOR,BTU ROUGH D ��6 Date Applicant 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 VALIDA ON with comply with such provisions or this permit shall be #2 420- deemed,revoked. FURNACE: FAU GRAVITY /O LICENSED CONTRACTORS DECLARATION FLOOR BTU 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. License Number,70,�// Lic. Class C- -a Contractor I—CDate U ❑ .I am exempt under Sec. ' U, Plan check fee IL B.&P.C. for this reason PERMIT ISSUING FEE $ /pj `v z TOTAL FEE Signature OWNER-BUILDE E RATION PLAN CHECK APPLICANT I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and NAME Professions Code): ❑ 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 TEL.NO. 7044, Business and Professions Code). OWNER ❑ I,as owner of the property, am exclusively contracting MAIL c=i with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY CITY TEL. NO. �5�g I hereby affirm that there•is a construction lending agency for p' the performance of the work for which this permit is issued CONTRACTOR /s meq/ (Sec. 3097, Civ. C.). , q ADDRESS .2 L /'+ 0EOr , Lender's Name L � vs TEL. NO. Lender's Address TE ?��7 LIC. e� ' I certify that I have read this application and state that the NSE NO J CLASS above information is correct. I agree to comply with all County ordinances and State laws relating to building construction, and hereby autho'z y+resentatives of this County to enter upon t above ofL�d property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of'A is or Agent Date WORKERS'COMPENSATION DECLARATION —3 It APPLICATION FOR PERMIT I hereby affirm that,I have,a certiflcote of consent to self insure,br a certificate of Workers'Compensation Insurdnce, . HEATANG - VENTILATING - AIR CONDITIONING er.g.certifted copy thereof(Sec. 3800 Lab. .) 76A364C �� CE-818(REV. 10/81) acy No. • Company Certified copy is hereby furgishec(. COUNTY OF LOS ANGELES BUILDING AND SAFETY Certified copy is filed with the unty bu' spec- FOR APPLICANT TO FILL IN BUILDING tion department. (PRINT OR TYPE ONLY) ADDRESS Date ffl4 Applicant —C/2 LOCALITY NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION coFRO ERS' NEAREST COMPENSATION INSURA CE CROSS ST. (This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT No. PRocEs the permit is for one.hundred dollars($100)or less.) AIR HANDLING UNIT,CFM d b I certify that in the performance of the work for which this O permit is issued, I shall not employ any person in any manner TU so as to become subject to the Workers'Compensation Laws. BOILER,BAPPROVALS DATE I PECR's SIGNu E Date Applicant COMPRESSOR,BTU--- (J ROUGH NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL Exemption, you should become subject to the Workers' d Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER v VALIDATI N with comply with such provisions or this permit shall be ao deemed revoked. FURNACE: FAU GRAVITY LICENSED CONTRACTORS DECLARATION FLOOR U D I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT '(commencing with Section 7000) of Division 3 of the Business WALL and Professions Code,and my license is in full force and effect. . t; License Number 0 � Lic. Class `— -,70 ® 0 �efa / of r Contractor 1 Date IQ ' ryy u 1': ❑ I am exempt u der Sec. lu Plan check fee CL B.&P.C. for this reason' Af PERMIT ISSUING FEE$ f'O e. TOTAL FEE Signature OWNER-BUILD CLARATION PLAN CHECK APPLICANT I hereby affirm that I am exemp rom the Contractor's License Law for the following reason (Section 7031.5, Business and NAME Professions Code): ❑ I, as owner of the property, or my employees with ADDRESS wages as their sole compensation,will do the work and CITY TEL. NO. the structure is not intended or offered for sale(Section 7044, Business and Professions Code). OWNER f7 � ❑ I,as owner of the property, am exclusively contracting r with licensed contractors to construct the project (Sec- MAIL ;2 ADDRESS 5 65.7 A tion 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY CITY TEL. NO. # 0 0 0 0 0 8 I hereby affirm that there is a construction lending agency for1 ° ° 4[I,5 0 the performance,of the work for which this permit is issued CONTRACTOR vp� (Sec. 3097, Civ. C.). e, o 0 4[�5 0 v ADDRESS e /y /� U Lender's Name CITY Gia TEL. NO. ��y'�/� 1 0. 1 5-86 Lender's Address STATE LIC. 0 I certify that I have read'this application and state that the LICENSE NO.30S31 CLASS C- above information is correct. I agree to comply with all County ordinances and State laws relating to building construction, and hereby a t representatives of this County to enter upon the ab a Zoned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of ppl' ant or Agent Date