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Home My Public Portal About5549-5549 1/2 SANTA ANITA AVE_Mechanical__ WQRKERS'COMPENSATION DECLARATION ✓ —'3� �7 APPLICATION IOR PERMIT I hereby.offirm that I have a certificate of consent to self CiDsure, otsa certificate of Workers'Compensation Insurance, 76A364C HEATING - VENTILATING - AIR CONDITIONING or a certified copy thereof(Sec. 3800, Lab. C.) CE-818(REV. 10/81) policy No% Company Y 4 ❑ Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY ❑ Certified copy is filed with the county building;nspec- FOR APPLICANT TO FILL IN BUILDING tion department. (PRINT OR TYPE ONLY) ADDRESS LOCALITY Date Applicant 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_y� the permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM � I certify that in the performance of the work for which this Jo ! b permit is issued, I shall not employ any person in an manner BOILER,BTU so as to become subject to the Workers'Compens ws. / APPROVALS DATE INs CTOR'S 5 .RE COMPRESSOR,BT G e 0� U ROUGH Date �� ^'Applicant NOTICE TO APPLICANT: If, after making th' rtificate of VENTILATION SYSTEM FINAL Exemption, you should become subject o e Workers' Compensation provisions of the Labor Code, you'must forth- EVAPORATIVE COOLER O� t VALIDATION with comply with such provisions or this permit shall be deemed revoked. FURNACE: FA GRAVITY LICENSED CONTRACTORS DECLARATION FLOOR BTU U I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED-UNIT— '(commencing USPENDED UNIT'(commencing with Section 7000) of Division 3 of the Business WALL and Professions Code,and my license is in full force and effect. s319 Lic �_ l� _ License Number , . Class 'Z U , � r�0 Contractor , Date�o �S O ❑ V I am exempt under Sec. UJ Plan check fee N B.&P.C. for this reason, ZT)atePERMIT ISSUING FEE$ 0 : TOTAL FEE ' Signature OWNER-BUILD CLARATION 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 CITY TEL. NO. the structure is not intended or offered for sale(Section 7044, Business and Professions Code). OWNER ❑ I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec- MAIL tion 7044, Business and Professions Code). ADDRESS 9565-2A CONSTRUCTION LENDING AGENCY CITY TEL. NO. 1 hereby affirm that there is a construction lending agency for , # 0 0 0 0 0 $ the performance of the work for which this permit is issued CONTRACTOR r �� ,� (Sec. 3097, Civ. C.). a o44,50 Lender's Name ADDRESS 1 r Cd v o o o 4.4,5 OZ CITY ,(�-7 TEL. NO. -�/�� I Q1 5-86 Lender's Address /) I certify that I STATE ? 0 5 7 have read this application and state that the LICENSE NO. J J � 51 LIC. CLASS G above information is correct. I agree to comply with all County ordinances and State laws relating to building construction, and hereby authori entatives of this County to enter upon the Bove-m ed roperty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Appl nt Agent Date ' WORKERS'COMPENSATION DECLARATION L_ 3 � 3�s-'7 PERMIT �GRIYl • I hereby affirm that I have a certificate of consent to self APPLICATION FOR IT'G insurelor a certificate of Workers'Compensdtion Insurance_ . '76A364C HEATING - VENTILATING - AIR CONDITIONING ora certified copy thereof(Sec. 3800, Lab. C.) CE-818(REV. 10%81) ❑Policy No. Company ', Certified copy is hereby furnished. ,. COUNTY OF LOS ANGELES. BUILDING AND SAFETY ❑ Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING 7� 0/' tion department.. �/1{ • (PRINT-OR TYPE ONLY) ADDRESS Date Applicant 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. PRO D BY the permit Is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM I certify that in the performance of the work for which this ✓✓✓ permit is issued, I shall not employ any person in any manner BOILER, BTU so as to become subject to the Workers'Com Ion LOWS. APPROVALS DATE INSP OR'S IGNA URE Dat.erf Q COMPRESSOR, BTU�-3 ROUGH !!�6�`�� Applicant NOTICE TO APPLICANT: If, after makinciAK Certificate of VENTILATION SYSTEM FINAL Exemption, you should become subj t to the Workers' Compensation provisions of the Labor Code, you must forth- EVAPORATIVE.COOLER VALIDAT N with comply with such provision's or this permit shall be deemed revoked. FURNACE: FAUGRAVITY LICENSED CONTRACTORS DECLARATION FLOOR BTU I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT '(commencing with Section 7000)of Division 3 of the Business - WALL and Professions Code,and my license is in full force and effect. License Number= / Lic. Class(--- f V 09 Contractor 1 Date `o�S= 6 ❑ I am exempt under Sec. d Plan check fee B,&P.C. for this reason 1144 PERMIT ISSUING FEE$ 50 z �Dp "Signature TOTAL FEE C10 OWNER-BUILDER DseLAWTION 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): - ElI, 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 CJ ❑' I, as owner of the property, am exclusively contracting MAIL with licensed contractors to construct the project-(Sec- ADDRESS 0 5 6 5 5 R tion 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY CITY TEL. NO. $f 0,0 0 o a 8 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued L4.2 R S C 40� J�/ (Sec. 3097, Civ. C.). b J a �V �_ °, Lender's Name US14� + TEL. NO.9� s�fyI Q 5-86 Lender's Address � LIC.I certify that I have read this application and state that the �-J.3 / CLASS VV above information is correct. I agree to comply with all County ordinances and State laws relating to building construction, and hereby author" r esentatives of this County to enter upon the above- d property for•inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE ,074 Signature of Ap is t or Agent Date