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HomeMy Public PortalAbout5637 SANTA ANITA AVE_Mechanical__ WORKER'S COMPENSATION certificate of consent to 76A348DPW9189 APPLICATION FOR PERMIT LIME GREEN I kerebq affhm;tjlat I have a certificate of consent to self Insure, 76A364C or a certificate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING copy thereof(Sec.3800 Lab.C.) Policy No. G - #7 RaCompany jM IC [/d'DC+fRrJI/ COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV. Certified copy is hereby furnished. FTFOR APPLICANT TO FILL IN BUILDING top j�g it a�/r// /LfI Certified copy is filed with the county buildi Inspection PRINT OR TYPE ONLY) ADDRESS �j J 1U 4 ArV�6!7�T IC department.q Q 1 ( Date —IV— ✓ ApplicantNO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY CERTIFICATE OF EXEMPTION FR S' NEAREST V COMPENSATION INSURANCE CROSS ST. ABSORPTION UNIT,BTU ASSESSOR (This section need not be completed if the work Involved by the MAP BOOK PAGE fad PARCELOV.3 permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO. PROCESSED BY I certify that in the performance of the work for which this permit (,O is issued, I shall not employ any person in any manner so as to BOILER,BTU become subject to the Workers'Compensation Laws. !V v r v �� --,Afa O COMPRESSOR,BTU APPROVALS DATE INSPECTOR'S SIGNATURE Date Applicant NOTICE TO APPLICANT: If, after making this Certificate of — ROUGH Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER provisions of the Labor Code,you must forthwith comply with such FINAL -!3A provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATION I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT (commencing with Section 7000)of Division 3 of the Business and HEATER: WALL Professions Code,and my license is in full force and effect. AAZ( ee 0 !n9 a v License Number �y�S'6S- Lic.Class ��l•lid.Alp,"ND i/f a to -2-2-8 /S .:r.30 130.? I O Coritractor� • ❑ I am exempt under Sec. Plan check fee O d 11 BAP.C.for this reason PERMIT ISSUING FEE$ ab6 C I•- Date: TOTAL FEE LL Signature C' PLAN CHECK APPLICANT U OWNER-BUILDER DECLARATION 2 1 hereby affirm that I am exempt from the Contractor's License Law NAME pool.for the following reason(Section 7031.5, Business and Professions 1 ITEMS Code): ADDRESS At -130. 35 ❑ I, as owner of the property, or my employees with wages TOTAL as their sole compensation, will do the work and the CITY TEL.NO. C structure Is not intended or offered for sale (Section 7044, '1 CHECK 13;0.{_F , Business and Professions Code). OWNER 4a&VT.,L L© W_ /AJ(l& /l! CHANGE ❑ 1, as owner of the property, am exclusively contracting .01;,I with licensed contractors to construct the project Sec- MAIL �,/ p j ( ADDRESS �21 ,-CiO I A C- tion 7044,Business and Professions Code). CITYS�NTS AA /1 TEL.NO. 131300-130131 irf 18!i:' CONSTRUCTION LENDING AGENCY ,J /T �r I hereby affirm that there is a construction lending a?ency for CONTRACTOR �� � /L��f e®/Vp1 �1 , Qs:r38 1 AM 8a°•1•? the performance of the work for which this permit s issued �-1 d IN IWC (Sec.3097,Civ.C.). Lender's Name `A ADDRESS I3"t{ Sk. 4,+D S CITY s,4raj I;OR IC-L TEL.NO. Lender's Address STATE }��� LIC. (faz v I certify that I have read this application and state that the above LICENSE NO. V CLASS C..Oz information is correct. I agree to comply with all County ordinances and State laws relating to building construction,and hereby authorize representatives 9f this County to enter upon the above-mentioned property in action purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE I C"rmem 0!! 4e V I IGNA RE OF APPLICANT AGENT DATE '