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HomeMy Public PortalAbout5547-5547 1/2 SANTA ANITA AVE_Mechanical__ I WORKERS'COMPENSATION DECLARATION < ^3`3.►--"�7 APPLICATION FOR PERMIT I hereby..affirm that I h9ve a cep/ificate of consent to self insumpor a certificate of Workers'Comperisation Insurance, 76dsbac HEATING - VENTILATING - AIR CONDITIONING - pr a certified copy thereof(Sec. 3800, Lab. C.) ^ CE-818(REV. 10/81) 4P❑olicy No. Company Certified copy is hereby f urnished, COUNTY OF LOS ANGELES I BUILDING AND SAFETY ❑ Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING ADDRESS �^ 7� tion department. (PRINT OR TYPE ONLY) Date Applicant r LOCALITY NO. TYPE OF APPLIANCE OR EQUIPMENT FEE 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. PROCESSED BY the permit is for one hundred dollars(;100)or less.) �r AIR HANDLING UNIT,CFM UG I certify that in the performance of the work for which this permit-is issued,I shall not employ any person in any manner BOILER,BTU so as to-become subject to the Workers'Comp ation Laws. cam/ APPROVALS DATE I PlE tOR'S SIGNATU Date/0 Applicant COMPRESSOR,BTU J v 0670 Q ROUGH ,9—` - NOTICE TO APPLICANT: If, after makin i Certificate of VENTILATION SYSTEM FINAL — zz 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 _ v deemed revoked. FURNACE: FAU GRAVITY • LICENSED CONTRACTORS DECLARATION FLOOR U I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED—UNIT— '(commencing USPENDED UNIT'(commencing with Section 7000)of Division 3 of the Business WALL and Professions Code,and my license is in full force and effect. 006 - r� l� _.L-K 0 License Number) '3� Lic. Class�V ® U / Q M 1 �� C9 Contractors Date �0 �5 ^�6 O ❑ I am exempt under Sec. Plan check fee 9L B.BP.C. for this reason' PERMIT ISSUING FEE$ 1149 r� � a Signaturqa&111922ft TOTAL FEE OWNER-BUILDERLA ION PLAN CHECK APPLICANT I hereby affirm that I am exempt rom t e Contractor's License Law for the following reason (Section 7031.5, Business and NAME Poo 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 El1, as owner of the property, am exclusively contracting + d/u with licensed contractors to construct the project (Sec- MAIL tion 7044, Business and Professions Code). ADDRESS CONSTRUCTION LENDING AGENCY CITY TEL. NO. 25654A I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued ;',t o 0 0 0 0 p P CONTRACTOR (Sec. 3097, Civ. C.). - 44,50 ADDRESS & �Or r'�j �v o� o o c 4 4,5 iy m Lender's Name —1 / CITY o3 a TEL. NO.�� ��/ 1 0, 1 5—8 6 Lender's Address STATE If �1 LIC. •1 certify that I have read this application and state that the [LICENSE NO._ ? CLASS 20 above information is correct. I agree to comply with all County ordinances and State laws relating to building construction, and hereby auth resentatives of this County to enter u n t ab o do ed property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE /v 16 Signature of Ap or Agent Date ". WORKERS'COMPENSATION DECLARATION s ` APPLICATION FOR PERMIT .I hereby affirm that I havq a certificate of consent to self insure,•ora certificate of Workers'Compensation Insure,- HEAUNG - VENTILATING - AIR CONDITIONING orp certified copy thereof(Sec. 3800 Lab. ) 76A3r54C ((�� CE-818(REV. 10/81) Policy No. Company d'y COUNTY OF LOS ANGELES' BUILDING AND SAFETY — erfi#i is hereby furnished. , Certified copy is filed w e county buil spec- FOR APPLICANT TO FILL IN BUILDING tion department. ADDRESS �Sy,Se�Qt /a /�„- n� (PRINT OR TYPE ONLY) , Date /V c/ Applicant 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. PROC the permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM L-�� L� + I certify that in the performance of the work for which this ✓ U v permit is issued,I shall not employ any person in ny manner BOILER,BTU 71, � so as-to become subject to the Workers'Cam S n LOWS. APPROVALS DATE SP OR'S SIGN TURE Date 112-1A �G+9pplicant COMPRESSOR,BTU'3_6J �� — ROUGH 777 NOTICE TO APPLICANT: If, after makingi ertificafe of VENTILATION SYSTEM FINAL Exemption, you should become subject to the Workers' v Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDAT with comply with such provisions or this permit shall be deemed revoked. FURNACE: FAU�GRAVITY LICENSED CONTRACTORS DECLARATION / FLOOR BTU I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED—UNIT— '(commencing USPENDED UNIT'(commencing with Section 7000)of Division 3 of the Business WALL and Professions Code,and my license is in full force and effect. O License Number 367t-�f �i Lic. Class V ©v (E DateContractor r ' O0 U Im ❑ I am exempt under Sec, t M Plan check fee IL BAP.C. for this reason 4n PERMIT ISSUING FEE$ SU z TOTAL OTAL FEE OWNER-BUILDE ARATION PLAN CHECK APPLICANT I hereby affirm that I am exempt am 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). V' j-� • OWNER (� OU ❑ I,as owner of the property,am exclusively contractingit with licensed contractors to construct the project (Sec- MAIL tion 7044, Business and Professions Code). ADDRESS 9 5 6 !i 5 A CONSTRUCTION LENDING AGENCY CITY TEL. NO. I hereby affirm that there is a construction lending agency for 0 0 0 0 0 8 the performance of the work for which this permit is issued CONTRACTOR ) '� (Sec. 3097, Civ. C.). d.5 ,1✓2 4 LI 5 Q ADDRESS 6 Nr ��� _ Lender's Name 0 0 0 4Q,5.n.6 CITY US a TEL. NO.(?/ Lender's Address Q 1 5-8 6 STATE LIC. �p V I certify that I have read this application and state that the LICENSE NO.0 6 JV CLASS 4 '� above information is correct. I agree to comply with all County ordinances and State laws relating to building construction, and hereby auth iz presentatives of this County to enter upon a abov i ed property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of App ca or Agent Date 0