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HomeMy Public PortalAbout5030 WILLMONTE AVE_Mechanical__ 1 , WORKERS'COMNENSATIGN DECLARATION CE-818(2-80) APPLICATION FOR PERMIT 1 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.) Policy No. 442586 Company State Fund Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY Certified copy is filed with the county building inspection I BUILDING department. APPLICANT TO FILL IN ADDRESS 10906 Wildflower .Road Date 77.4-1V 2Appiicant AAA Cond. Air. Inc. (PRINT OR TYPE ONLY) LOCALITY • CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE COMPENSATION INSURANCE NEAREST } CROSS ST. (This section need not be completed if the work involved ABSORPTION UNIT,BTU fi by the permit is for one hundred dollars (5100) or less.) ' DISTRICT NO. PROCESSED BY V I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM permit is issued, I shall not employ any person in any manner it 0 so as to become subject to the Workers'Compensation Laws. BOILER,BTU APPROVALS DATE INSPECTOR'S SIGNATURE Date Applicant COMPRESSOR.-BTU ROUGH ti NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL 'e 2 Exemption, you should become subject to the•Workers' 3' — Compensation provisions of the Labor'Code,you must forth- EVAPORATIVE COOLER VALIDATION with comply with such provisions or this permit shall be ,deemed'revoked. FURNACE: FAUJU0, VITY LICENSED CONTRACTORS DECLARATION 1 FLOOR: BTU— I I hereby affirm that I am licensed under provisions of Chapter 4 HEATER: SUSPENDED UNIT 9 (commencing with Section 7000)of Division 3 of the Busi- I WALL ness and Professions Code, and my license is in full force and effect. �J License Number 293529 Lic.Class C20 Contractor AAA Cond. A.Vte 12/I6/82 ElI am exempt from the licensing requirements as I 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$ Lic,or Reg.No. Date TOTAL FEE ' HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT II hereby affirm that I am exempt from-the Contractor's NAME L(cense Law for the following reason (Section 7031.5, Busi- pess and Professions Code): ,ADDRESS ❑ I, as owner of the property; will do the work and the CITY TEL.NO.. ' structure is not intended or offered. for sale (Section tq 41 P. 7044, Business and Professions Code). ,. 0 I as owner of the OWNER property, am exclusively contracting kaXe « u o 0 0 0 .I with licensed contractors to construct the project MAIL (Section 7044,Business and Professions Code). rZDRESS o o 3 2 / 5 CONSTRUCTION LENDING AGENCY CITY TEL.NO. Q— ���'� ;1 .� •�•:y I hereby affirm that there is a construction lending agency CONTRACTOR for the performance of the work for which this permit is I ? 1 7-6 2 issued(Sec.3097,Civ.C.).- Lender's .).Lender's Name' ADDRESS 10160 E. Valleg BZ Lender's Address 81TY TEL.NO. I certify that I have read this application and state that the SfTATE LIC. above inforniatio.n is correct.I agree to comply with all County LICENSE NO. 2-93529 CLASS C20 ordinances and State laws-regulating Heating, Ventilating and 44 Air Conditioning,and hereby authorize representatives of this I• SEE REVERSE FOR EXPLANATORY LANGUAGE County to enter up. i he above-mentioned properly for inspection purposes. 'IDckidd rng (. 12/16/82 Signature of Permittee Date WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT racertified y affirm that I have o certificate of consent to self or a certificate of Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONS LNG c py thereof Sec. 3800, Lab. C.), 76A364C �.�,� CE-818(REV. 10/81) ,_,-,� Policy N07 �w, Company ---.L%,+ , y Z❑ L, I C AND SAFETY Certified copy is hereby furnished. 6,-0 -T OF LOS ANGELES BUILDING ❑ Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING D ' tion department. � (PRINT OR TYPE ONLY) ADDRESS � Date-L——) Applicant Q LOCALITY NO. TYPE OF APPLIANCE OR EQUIPMENT ` FEE BTU NEAREST , CERTIFICATE OF EXEMPTION FROM WORKERS' ' COMPENSATION INSURANCE t0 F� CROSS ST. (This section need not be completed if the work involved by ABSORPTION UNIT, 1{ � / DISTRICT NO PROCESSED BY the permit is for one hundred dollars ($100)or less.) AIR HANDLING UNIT, CFM o ©�T 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'Corn nsat'on Lo s. APPROVALS DATE INSPECTOR'S SIGNATURE Date 7 'a Applicant COMPRESSOR, BTUJ- t C?tf 0 ROUGH NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION with comply with such provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY LICENSED CONTRACTORS DECLARATION FLOOR BTU 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 er , and Professions Code,and my licensee is in full force and effect. IL License Number �`7 Lic. Class U U ContraCtOL te ❑ I am exempt under Sec. LU U Plan check fee C6 N B.&P.C. for this reason Z Date: PERMIT ISSUING FEES 10 57V Signature / TOTAL FEE OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT I hereby affirm that I am exempt from the Contractor's Licenseto , Law for the following reason (Section 7031.5, Business and NAME V- Professions Code): ❑ I, 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 ❑ 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 CONSTRUCTION LENDING AGENCY CITY TEL. NO. I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued t/ CONTRACTOR y^{J t. j( (Sec. 3097, Civ. C.). p� ADDRESS Z ! ! C,(B4-l i-a-st-e Lender's Name CITY �' � TEL. N .7/r Lender's Address / STATE r7 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 ordinances and State laws relating to building construction, and hereby authorize representatives of this County to enter upon the above- entioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent Date