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Home My Public Portal About9420-9422-9424 WOODRUFF AVE_Mechanical__ CE-818(2-80) �P P L 2 WORKERS'COMPENSATION DECLARATION 76A364C p�IC AT 0®II��p l FOR P E R� T I hereby affirm that I have a' certificate of consent to self a certified "fl insure, or a certificate of Workers'Compensation Insurance,or HEATINGE:NTILATING-AIR CONDITIONING a certified o y a (Sec.3800, ) _ f Polic. Company - ❑ Certified copy is.hereby furnished. COUNTY OF LOS ANGELES q BUILDING AND SAFETY 19 Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN BUILDING dede r� Alp plicant tel' l L (PRINT OR TYPE ONLY) ADDRESS Date �— LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE COMPENSATION INSURANCE NEAREST CROSS ST. L d (This section need not be completed if the work involved ABSORPTION UNIT, BTU p by the permit is for,one hundred dollars ($100) or less.) I DISTRICT NO. PROCESSED BY V I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM vO permit is issued, I shall not employ any person in any manner i so as to become subject to the Workers'Compensation Laws. BOILER,BTU (3 Q �. APPROVALS DATE INSPECTOR'S SIGNATURE W Date Applicant C COMPRESSOR,BTU O ROUGH d�a "�^-� N NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL � r� �. ,!__ ,,,_ Z Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION with comply with such provisions or this permit shall be Q' deemed revoked. / FURNACE: FAU GRAVITY J LICENSED CONTRACTORS DECLARATION FLOOR:S BTU n I hereby affirm that I am licensed under provisions of Chapter HEATERSUSPENDED UNIT 1 2 5A 9 (commencing with Section 7000,)of Division 3 of the Busi- WALL ness and Professions Code, and my license is in full force and erect. # o o e o 8 8 License Number Lic.Class 2 0 0 2 700 Contractor Date o 0 o27,000' El am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer Plan check fee 25%of above. 0 9 2 1 —8 1 acting in my professional capacity (Section. 7051, Bus- 0 ISSUING FEE$ iness and Professions Code). Lic.or Reg.No. Date TOTAL FEE a HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT I hereby affirm that 1 am exempt from-the Contractor's NAME License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): ADDRES ❑ I, as owner of the property, will do the work and the ' . �i structure is not intended or offered for sale (SectionCITY TELN 7044, Business and Professions Code). ❑ OWNER I, as owner of the property, am exclusively contracting with licensed contractors to construct the project MAIL (Section 7044, Business and Professions Code). ADDRESS 0 CONSTRUCTION LENDING AGENCY CIT TEL.NO. ��-3(� I hereby affirm that there is a construction lending agency CONTRACTOR for the performance of the work for which this permit isC. G issued Sec.3097,Civ.C.). Lender.s Name ADDRESS Lender's Address CITY'� � TEL.NOa� I certify that I have read this application and state that the STATE ,1 LIC. �a above information is correct.I agree to comply with all County LICENSE NO. �y�8' 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 'I iu ti7pu. • aEr ^� l— O Signature of Permittee Date WORKERS'COMPENSATION DECLARATION ! CEA 81 8C(2-80) 6=1 Ir If�LLQ��b i� ®u u O R P E R ivU T �p I hereby affirm that I have W certificate of consent to self I insure,or a certificate of Workers'Compensation Insurance,of I B-IEATIWCs_VENTILATIWG_AIR CONDITIONING a certifiedcopy�li�es�(Sec.380.0, /fes�I Polic.��Njtt��rYYOO J Company ' - F1 Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING ARID SAFETY 19 Certified copy is filed with the county building inspection FORAPPLICANT TO FILL IN BUILDING dea)r—tm�3 // a Date 'Afpplicant- ' lC v - (PRINT OR TYPE ONLY) ADDRESS • LOCALI lY ^ % AT 1Z CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE COMPENSATION INSURANCE NEAREST (This section need not be completed if the work involved ABSORPTION UNIT,BTU CROSS ST. CLO by the permit is for,one hundred dollars ($100) or less.) DISTRICT NO. PROCESSED BY V I certify that in the performance of the work for which this"z AIR HANDLING UNIT,CFM cc permit is issued, I shall not employ any person in any manner �� d p so as to become subject to the Workers'Compensation Laws. BOILER,BTU H ' � APPROVALS DATE INSPECTOR'S SIGNATURE W Date Applicant COMPRESSOR,BTU C3(5 t% ROUGH ( ' `� 4vt' N NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM s a f Z Exemption, you should become 'subject to the Workers' FINAL Compensation provisions of the Labor Code,you must forth- EVAPORATIVE COOLER X/ALIDATICA with comply with such provisions or this"permit shall be deemed revoked. J �J LICENSED CONTRACTORS DECLARATION FLOOR, FAU BTU GRAVITY �j I hereby affirm that I am licensed under provisions of Chapter HEATERS SUSPENDED UNIT 9 (commencing with Section 7000)of Division 3,of the Busi•' WALL" I 12(a 5 A ness and Professions Code, and my.license'is in full force and ' O O —effect.• # -o o;o o•.V V License Number Lic.Class 2 o270.0 2 7.C7 Contractor. Date e G27,006 ❑ •1'am exempt from the licensing requirements as I am a ` licensed architect or a'registered professional engineer Plan check fee 25%of above. 0 9.2 1 -8 1 acting in my professional capacity (Section 7051, Bus- iness•and Professions Code). PERMIT ISSUING FEE$ Lic.or Reg.No. Date. TOTAL FEE HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT 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): ADORES ❑ I,°as,.owner of the. property, will do the work and the' ' TE L.N fi structure is not intended or offered for sale (Section. CITY 7.044;Business and Professions Code). ❑ Gnu_v_C.-ear/ I, as owner of the property, am exclusively contracting OWNER with licensed contractors to construct the project MAIL (Section 7044,Business and Professions Code). ADDRESS 0 CONSTRUCTION LENDING AGENCY CIT .. _TEL.NOA6 -56 , I hereby affirm that there is a construction lending agency CONTRACTOR for the performance of the work for which this permit is G issued SSec.3097,Civ.C.). Lender s Name ADDRESS Lender's Address CITY � TEL.NO I certify that I have•read.this application and state that the STATE ,f LIC. above.information is correct:I agree to cordply with all County L:ICE.NSE NO. Y�� CLASS ordinances and State laws regulating Heating,Ventilating'and Air Conditioning,and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE County to enter upon the above-mentioned property for ,tion putposeCs. 0 Signature of Permittee Date..