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HomeMy Public PortalAbout5555 1/2 SANTA ANITA AVE_Mechanical__ I WORKERS'COMPENSATION DECLARATION. 5^3���, APPLICATION FOR PERMIT I,,hereby.affirm that I have a certificate of consent to self iq.sure_, pr b certificate of Workers'Compensation Insdr9nce, E- 01HEMING - VENTILATING - AIR CONDITIONING or a certified copy thereof(Sec. 3800, Lab. C.) C818 CE Bl B(REV. 10/81) Policy No! - Company y . Certified copy is hereby fprnished.. COUNTY OF LOS ANGELES BUILDING AND SAFETY ❑ Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING IP-_e-77 � S ��ryf tion department. (PRINT OR TYPE ONLY) ADDRESS �� �/t! 77 Date Applicant LOCALITY • , NO. TYPE OF APPLIANCE OR EQUIPMENT FEE' ' CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST COMPENSATION INSURANCECROSS ST. aTff:_%f_ (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($100)or less.) -AIR HANDLING UNIT,CFM p 1 certify that in the performance of the work for which this �/c P \ J permit is issued,I shall not employ any person in any m er BOILER,BTU so as to become subject to the Workers'Co pe L S. ? APPROVALS DATE NSP TOR'S SIGN TURE Q. . COMPRESSOR, BTU ✓ O ROUGH Date pplicanf NOTICE TO APPLICANT: If, after making t sIficate of VENTILATION SYSTEM FINAL Exemption, you should become subject to a Workers' Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATr6N with comply with such provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY U LICENSED CONTRACTORS DECLARATION FLOOR U' I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT '(commencing with Section 7000)of Division 3 of the Business WALL and Professions Code,and my license is in full force and effect. IL © 3/License Number Lic. Class ,` 1/ 1 /� Contractor Date a/0�^� °A Ov 7 � /S 1 0 ❑ I am exempt under Sec. Au d Plan check fee B.&P.C. for this reason' PERMIT ISSUING FEE$ 10 .5-0 � Signature TOTAL FEE . OWNER-BUILDER 610ATION PLAN CHECK APPLICANT I hereby affirm that I am exempt fr m 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 J . A 5 6 G,6 A 7044, Business and Professions Code). 0 0 0 0 0 8 OWNER O El 1, as owner of the property,am exclusively contracting # with licensed contractors to construct the project (Sec- MAIL fion 7044, Business and Professions Code). ADDRESS 1 ­ 41.150 CONSTRUCTION LENDING AGENCY CITY TEL. NO. 0 0 0 I hereby affirm that there is a construction lending agency for 4 4 5�' the performance of the work for which this permit is issued CONTRACTOR (Sec. d Ca ® ( (J, 5-86 (Sec. 3097, Civ. C.). ADDRESS pe �� t' v t9� Lender's Name CITY ✓S, TEL. NO. Lender's Address STATE `1 � /gyp' LIC. ' I certify that I have read this application and state that the LICENSE NO. �/ / CLASS above information is correct. I agree to comply with all County . e ordinances and State laws relating to building construction, and hereby author' re resentatives of this County to enter <_ u n t abov o d property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Date Signature of A or Agent i WORKERS'COMPENSATION DECLARATION �.^ —�j ''Z APPLICATION Flo® PERMIT �'r III I hereby affi=m that I have a certificate of consent to self IT R ! M .insure, os a certificate of Workers'CompenStition Inswance, J1 76A364C o HEATING - VENTILATING - AIR CONDITIONING or a certified copy thereof(Sec. 3800, Lab. C.) ! CE-818(REV. 10/81) Policy Noa Company ❑ Certified copy is hereby furnished. COUNTY OF LOS ANGELES. BUILDING AND SAFETY ❑ Certified copy is filed with the founty building inspec- FOR APPLICANT TO FILL IN BUILDING ! � tion department. (PRINT OR TYPE ONLY) ADDRESS AZ 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. PROCESSED BY the permit Is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM d I certify that in the'peiformance of the work for which this v� permit is issued, I shall not employ any person in any manner so as to-become subject to the Workers'Comp on Laws. BOILER, BTU' /� APPROVALS DATE INSPE O4SIGNRE Date_l�r6 �6 Applican v COMPRESSOR,BTU' U �(/ ROUGH NOTICE TO APPLICANT: If, after making Certificate of VENTILATION SYSTEM FINAL / Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDAT, N with comply with such-provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY r/qu LICENSED CONTRACTORS DECLARATION FLOOR BTUI herebyaffirm that I am licensee(under provisions of Chapter 9 HEATER:. SUSPENDED UNIT '(commencing with Section 7000)of Division 3 of the Business. - WALL and Professions Code,and myylicceenseis in full force and effect. CL wo O License Number / 7 Lic. Class ' ad ad Contractor S —Date/ ❑ V I am exempt under Sec. � Plan check fee n. U) BAP.C. for this reason' PERMIT ISSUING FEE$ /'Q TOTAL FEE Signature OWNER-BUILDE D ARATION 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)-- EJ ode)❑ 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- MAIL S Tion 7044, Business and Professions'Code). z'5650A CONSTRUCTION LENDING AGENCY CITY TEL. NO. I hereby affirm that there is a construction lending agency for # 0 0 0 o a 8 the performance of the work for which this permit is issued CONTRACTOR (Sec. 3097, Civ. C.). 10 - 44,50 ADDRESS Lender's Name o a 0 411 5 0 CITY � TEL. NO. ' Lender's Address I Q 15-86 STATE LIC. 1 certify that I have read this application and state that the LICENSE NO. CLASS above information is correct. I agree to comply with all County ordinances and State laws relating to building construction, and hereby authorize re resentatives of this County to enter upon th above- n d property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature Qf AW1c r Agent Date WORKERS'COMPENSATION DECLARATION �•� �+ 3� hereby affirm thpt I haye a certificate of consent to self APS IGATIO I F®R PERMIT insure, or a certificate of Workers'Compensation InsL/rence HEATING - VENTILATING - AIR CONDITIONING cu.a certified copy thereof(Sec. 3800,'Lab. C.) 76A364C CE-818(REV. 10/81) Policy No.' Company Certified copy is hereby furriished. 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 tion department. (PRINT OR TYPE ONLY) Date Applicant LOCALITY Za le" � NO. TYPE OF APPLIANCE OR EQUIPMENT - FEE �� CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST COMPENSATION INSURANCE j CROSS ST. g (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($100)or less.) AIR HANDLING UNIT,CFM I certify that in the performance of the work for which this a r/ permit is issued, I shall not employ any'person in any manner BOILER,BTU so as to become subject to the Workers'Comp n LAWS. APPROVALS DATE INS CTOR'S SIG TURE Date pplicanf COMPRESSOR, BTU ROUGH NOTICE TO APPLICANT: If, after making is~ertificate of VENTILATION SYSTEM FINAL Exemption, you should become subject t the Workers' Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER• _) VALIDAT N with comply with such provisions or this permit shall be V deemed revoked. FURNACE: FAU GRAVITY LICENSED CONTRACTORS DECLARATION FLOOR I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT '(commencing with Section 7000) of Division 3 of the Business WALL '„ and Professions Code,and my license is in full force and effect. 12. License Number fJ Lic. Class W r v - / ® @9 Contractor Date���� o� O ❑ U I am exempt under Sec. Plan check fee a 4A'B.&P.C. for this reason' PERMIT ISSUI G FEE$ � TOTAL FEE ,fO Signature OWNER-BUILDEfdefARATION 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 compehsation,will do the work and CITY TEL. NO. the structure is not intended or offered for sale(Section 7044, Business and Professions Code). OWNER ❑ 1,as owner of the property, am exclusively contracting MAIL with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code). 5 65•1 A CONSTRUCTION LENDING AGENCY CITY TEL. NO. I hereby affirm that there is.a construction lending agency for # o o 0 0 0 8 the performance of the work for which this permit is issued CONTRACTOR (j [(�5 (Sec. 3097, Civ. C.). ADDRESS 2 `o r ,to V ' o o 0 4 i,5 G Lender's Name a/ CITY a ' TEL. NO. ��/ I Q 1 5_86 Lender's Address STATELIC. I certify that I have read this application and state that the - LICENSE NO. ��� CLASS ^ above information is correct. I agree to comply with all County ordinances and State laws relating to building construction, and hereby autho ' e representatives of this County to enter upon the above a ned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Awcionr Agent Date i