The URL can be used to link to this page

Home My Public Portal About5553-5553 1/2 SANTA ANITA AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION � � e I hereby,affirm that I have a certificate of consent to self - APPLICATION FOR PERMIT insure,'or a certificate of'Workers'Compenba.)t!on Insurance, or a certified copy thereof(Sec. 3800, Lab. C769364C�. HEATING - VENTILATING - AIR CONDITIONING CE-818(REV. 10/81) Policy No Company + . 1L'J� 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 ADDRESS J-J,<3 tion department. (PRINT OR TYPE ONLY) 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 C BY the permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM �^ tJ I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to becomte subject to the Workers'Comp Laws. BOILER,BTU ter' APPROVALS DATE NSP OR'S SIGNAT RE Date �g �Applican 'Ar �— COMPRESSOR, BTU ��V �U ROUGH NOTICE TO APPLICANT: If, after making t0/1116ertificate of VENTILATION SYSTEM FINAL / y Exemption, you should become subject t the Workers' zz Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER V LIDA I N with comply with such provisions or this permit shall be deemed revoked. FURNACE: FAL1 RAVITY LICENSED CONTRACTORS DECLARATION FLOOR B I hereby affirm that I am licensed Under provlisions of Chapter 9SUSPENDED UNIT '(commencing with Section 7000)of Division 3 of the Business HEATER: WALL and Professions Code,and my license is in full force and effect. Off. ILS r f O License Number--?06,7/57 Lic. Class O > Contractor — 4:� Date ze,-,&—4914, t— ❑ I am exempt under Sec. Lu Plan check fee Ivy B.&P.C. for this reason PERMIT ISSUING FEE$ d !}'D z te: Signature TOTAL FEE OWNER-BUI R 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 Professi6ns Code): ❑ I, as owner of the property, or my emp)oyees with ADDRESS wages as their sole compensation,will do the work and CITY TEL. NO. the structure is nbt intended or offered for sale(Section 7044, Business and Professions Code). /— J L l�w.LL El I, I, as owner of the property, am exclusively contracting MAIL with licensed contractors to construct the project (Sec- ADDRESS 5 6 4 Sion 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY CITY TEL. NO. 0 0 0 0 0 8 1 hereby affirm that there is.a construction lending agency for the performance of the work for which this permit is issued CONTRACTOR rCJr' L/ .�y�v a4'A' ® ( ° ° 4 4 5 l7 (Sec. 3097, Civ. C.). ADDRESS ;2 7`2 0 0 0 4 4,5 Q Lender's Name l CITY Us TEL. NO. �� f/ I O, 1 5-86 Lender's Address TE Jzz ` �! TA I certify that I have read this application and state that the LICENSE NO.J��3/ CLASS above information is correct. I agree to comply with all County ordinances and State laws relating to building construction, and hereby authori ?rresentatives of this County to enter u on a above nte property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of A p ant Agent Date WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT I hereby affirm that I have:a certificate of consent to self insure'or a certiftcate o#Workers'Comperisation Insurance, or a certified copy thereof(Sec. 3800, Lab. C.) 76A3ea�'4" . --kIE.�TING - VENTILATING - AIR CONDITIONING 11 CE-818(REV. 10/81) ~ .Policy N9. Company o. 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 �V 5– n r tion department. (PRINT OR TYPE ONLY) ADDRESS �j / .f /Lt!/ Date Applicant LOCALITY a 1 NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST COMPENSATION INSURANCE CROSS ST. :i2= (This section need not be completed if the work Involved by ABSORPTION UNIT, BTU DISTRICT NO. PROCESS D BY the permit is for one hundred dollars($100)or less.) ^ AIR HANDLING UNIT,CFM d �� I certify that in the performance of the work for which this permit is issued, I shall not employ any person in n manner so as to become subject to the Workers'Comp Laws. BOILER, BTU APPROVALS DATE N ECTOR'S SI ATURE r COMPRESSOR, BTU �� D ROUGH 1_4 IdMA Date Applicant, NOTICE TO APPLICANT: If, after making thif rtificate of VENTILATION SYSTEM FINAL Exemption, you should become subject iro4the Workers' Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLERVALIDA ON with comply with such provisions or this permit shall be deemed revoked. FURNACE: FAUGRAVITY LICENSED CONTRACTORS DECLARATION FLOOR BTU U Irhereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED-UNIT— '(commencing USPENDED UNIT'(commencing with Section 7000)of Division 3 of the Business - WALL and Professions Code,and my license is in full force and effect. a 4, �'1 9 O License Number_g6�/ Lic. Class_ I �s �a�/s=�6 Civ Date 0 Contractor t- ETI am exempt un er Sec. W Plan check fee w o- B.&P.C. for this reason' N PERMIT ISSUING FEE$ U z a —FT FEE Signature ' OWNER-BUILDO'DEffARATION 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 MAIL with licensed contractors to construct the project (Sec- ADDRESS 5 b 7 A tion 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY CITY TEL. NO. 4 0 0 0 a 0 8 I hereby affirm that there is a construction lending agency for the performance of the work for which,this permit is issued CONTRACTOR / I 0 0 4 a,5 0 (Sec. 3097, Civ. C.). d a o 0 0 ADDRESS [I q,5 0 Lender's Name ��6 �- CITY U TEL. NO. I Q 1 5-86 Lender's Address 96 7-4 STATE Z7 LIC. I certify that I have read this application and state that the LICENSE NO. rJ� CLASS 0 above information is correct. I agree to comply with all County ordinances and State I ws relating to building construction, and hereby ah iz esentatives of this County to enter u n above oned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE —gel Signature of App/ an r Agent Date 7-1 78A364-;EBIB-./7D APPLICATION FOR PERMIT HEATING - VENTILATING - AIR CONDITIONING COUNTY OF LOS ANGELES BUILDING p DEPARTMENT OF COUNTY ENGINEER ADDRESS 's� td Art,"T v-e-, BUILDING AND SAFETY DIVISION LOCALITY JOHN A. LAMBIE. COUNTY ENGINEER NEAREST j r COLEMAN W. JENKINS, SUPERINTENDENT OF BUILDING CROSS ST.fi/I C U /� FOR APPLICANT TO FILL IN OWNER 1 -77S A -a v,( (PRINT OR TYPE ONLY) �a'� MAIL _ NO. TYPE OF APPLIANCE-OR EQUIPMENT FEE ADDRESS CITY J� �iY TEL. NO. ABSORPTION SYSTEM, BTU ij CONTRACTOR V w 11 m V, AIR HANDLING UNIT, CFM ADDRESS r BOILER, HORSEPOWER CITY TEL. NO. COMPRESSOR, HORSEPOWER STATE LIC. LICENSE NO. CLASS VENTILATION SYSTEM i DISTRICT NO. CLASS GROUP ZONE PROC SSEO BY EVAPORATIVE COOLER FURNACE: FAU_GRAVITY INSPECTION RECORD FLOOR-- BTU HEATER: SUSPENDED UNIT yo WALL ✓ C - � C C C F C L • C C ` NEW—ADDITION— PERMIT $ 3 00 ALTER—REPAIR_ TOTAL FEE $ PLAN CHECK APPLICANT NAME a r I ADDRESS S- j �'� S Z Nl L�T3. �ir CITY TE NO I HEREBY ACKNOWLEDGE 4HAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY WITH ALL ORDINANCES AND LAWS REGULATING HEATING, VENTI- APPROVALS D E INS OR'S yGN URE LATING,AIR CONDITIONING. ROUGH I HEREBY CERTIFY THAT I AM NOT ACTING IN VIOLATION OF CHAPTER 9, DIVISION 3, OF THE BUSINESS AND PROFESSIONALI WIG FINAL CODE OF THE STATE OF CALIFORNIA. SIGNATURE JACK R. ALLEN,SU ERVISING MECHANICAL ENG' i• OF PE RMI TT �.. -� PERMIT VALIDATION CK. M.O. CASH PLAN CHECK VALID.AT N ,. i tr., 7 b 5 3'c- NOIV17 4 1 D 7.0 0- SEE BACK OF APPLICATION FOR COM PLETE FEE SCHEDULE