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Home My Public Portal About5502 WELLAND AVE_Mechanical__ WEYRKt RS'COMPENSATION DECLARATION CEA 818(2-80) APPLICATION FOR P E R llnt! T I.hereby affirm that I have a• certificate of consent to self insure,or a certificate of Workers'Compensation Insurance,or ' HEATING-VENTILATING-AIR CONDITIONING a certified copy thereof(Sec.3800,Lab.C.) • I Policy No. Company ❑- Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING ARID SAFETY I Certified copy is filed with the county building inspection I FOR APPLICANT TO FILL IN BUILDING department. ADDRESS _6o � u Date Applicant (PRINT OR TYPE ONLY) LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE COMPENSATION INSURANCE NEAREST r^�'- (This section.need not be completed if the work involved ABSORPTION UNIT, BTU CROSS ST. .�1he- �- 0 by the permit is for one hundred dollars ($100) or less.) DISTRICTY.0�/ P OCESSED BY 0 I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM Cc permit is issued, 1 shall not employ any person in any manner a O so as to become subject to the Workers' Compensation Laws. BOILER,BTU t APPROVALS DATE INSPECTOR'S SIGNATURE lJ.) Date Applicant COMPRESSOR,BTU ROUGH 1/�� N NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL Y Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- with comply with such provisions or this permit shall be EVAPORATIVE COOLER VALIDATION deemed revoked. FURNACE: FAU 11 GRAVITY LICENSED CONTRACTORS DECLARATION FLOOR: BTU - I hereby affirm that 1 am licensed under provisions of Chapter HEATER: SUSPENDED UNIT 9 (commencing with Section 7000) of Division 3 of the Busi- WALL ness and Professions Code, and my license is in full force and effect. License Number Lic.Class Contractor Date I am exempt from the licensing requirements as 1 am a licensed architect or a registered professional engineer Plan check fee 25%of above. acting in my professional capacity (Section 7051, Bus- iness and Professions Code). PERMIT ISSUING FEE p Lic.or Reg.No. Date TOTAL FEE HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT I hereby affirm that I am exempt from-the Contractor's NAME License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): ADDRESS p ip�(�;w•�il. 1, as owner of the .property, will do the work and the ACCTA structure is not intended or offered for sale (Section CITY C - TEL.NO.�t�lL� n-7 �fn �n 7044, Business and Professions Code). 330( .t0.50 I, as owner of the property, am exclusively contracting OWNER �C- Hyl 1 ITEMS with licensed contractors to construct the project MAIL 1J�� r1 A ,rt (Section 7044, Business and Professions Code). ADDRESS Jam- TOTAL 21131.50 CITY TEL.N0.CR CHECK ryty�q I CONSTRUCTION LENDING AGENCY C R Oft 4f1 <u ,J I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is CONTRACTOR CHANGE �� issued(Sec.3097,Civ.C.). Lender's Name ADDRESS nnt� Lender's Address CITY TEL.NO. 10/19/89 I certify that I have read this application and state that the (STATE LIC. 62961 �� g��t- above information is correct.I agree to comply with all County LICENSE NO. CLASS ordinances and State laws regulating Heating,Ventilating and Air Conditioning,and hereby authorize representatives of this i SEE REVERSE FOR EXPLANATORY LANGUAGE County to enter upon the above-mentioned property for inspection purposes. Signature of Permittee Date � WORKER'S COMPENSATION DECLARATION 20.0046 DPW 9/89 LIME GREEN I herl�by affirm that i have a certificate of consent to self insure, 76A3e4C APPLICATION FOR PERMIT or a cbrtificate of Worker's Compensation Insurance,or a certified HEATING-VENTILATING-AIR CONDITIONING copy thereofKSec.3800 Lab.C.) Policy N6' Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV. ❑ Certified copy is hereby furnished. ❑ Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN BUILDING J9-vtr� department. (PRINT OR TYPE ONLY) ADDRESS Date Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST r CROSS COMPENSATION INSURANCE ABSORPTION UNIT BTU ASSESSOR (This section need not be completed If the work Involved by the MAP BOOK PAGE PARCEL permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO. PROCESSED BY I certify that in the performance of the work for which this permit Is issued. I shall not employ any person in any manner so as to BOILER.BTU n Q become subject to the Workers'Compensation Laws. v �-� COMPRESSOR,BTU Date / /Applicant l / ( VENTILATION SYSTEM I APPROVALS DATE INSPECTOR'S SIGNATURE NOTICE TOAPPLICANT: If, after making his Certificate of ROUGH Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER J- provisions of the Labor Code, you must forthwith comply with such FINAL �-1)9 provisions or this permit shall be deemed revoked. FURNACE: FAU 11. GRAYVffY LICENSED CONTRACTORS DECLARATION / FLOOR BTU VALIDATION 1 hereby affirm that I am licensed under provisions of Chapter 9 HEATERSUSPENDED UNIT : (commencing with Section 7000) of Division 3 of the Business and WALL Professions Code,and my license Is In full force and effect. & License Number Lic.Class��(s� s� ® ti Contractor_�Qgg ,� �,� ate �� ❑ 1 am exempt under Sec. Plan check fee Cc B.&P.C.for this reason PERMIT ISSUING FEE$C;241 C D te: TOTAL FEE O� �c ri'-{ U. Signature .11-Lit' 101.MISI a OWNER-BUIL LARATION PLAN CHECK APPLICANT 2 1 hereby-affirm that I am exempt from the Contractor's License Law NAME ® TOTAL �. �.® , for the following reason(Section 7031.5, Business and Professions Code): ❑ ADDRESS CHECK 101.89 1, as owner of the property, or my employees with wages iL r+ as their sole compensation, will do the work and the CITY TEL.NO. CHil (3 .10 structure is not intended or offered for sale(Section 7044, Business and Professions Code). OWNER ~�— ❑ 1, as owner of the property, am exclusively contracting MAILS n (01300-101Q0i 9/IL/92 with licensed contractors to construct the project (Sec- ADDRESS « tion 7044,Business and Professions Code). I i AM 3i)o _� CONSTRUCTION LENDING AGENCY CITY r TEL.'NO. I hereby affirm that there is a construction lending agency for CONTR CTOR v .P the performance of the work for which this permit Is issued (Sec.3097,Civ.C.). A L ADDRESS ae Lender's Name CITY TEL.NO. Lender's Address C_ Q I certify;hat I have read this application and state that the above IL CENSE NO. CLLASS information is correct. I agree to comply with all County ordinances And State laws relating to building construction,and hereby authorize representatives of this County to enter upon the above-mentioned propert action purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Aww SIGNATUR DATE I