The URL can be used to link to this page

Home My Public Portal About9726 WOOLLEY ST_Mechanical__ WORKER'S COMPENSATION DECLARATION 20-0046 DPW 9/89 APPLICATION FOR PERMIT LI E GREEN I hereby affirm that I have a certificate of consent to self insure, 7f3A3fi4C or a certificate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING copy thereof(Sec.3800 Lab.C.) Policy No. 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 ADDRE S department. (PRINT OR TYPE ONLY) LOCALITY Date Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST. 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(3100)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 I BOILER,BTU 4_100111' p' become subject to the Workers'Compensation Laws. 100 k �L��/ COMPRESSOR,BTU On i-o-0 APPROVALS DATE INSPECTOR'S SIGNATURE Date Applicant VENTILATION SYSTEM 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 provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVI / fy LICENSED CONTRACTORS DECLARATION FLOOR BTU 0-0-6 6- VALIDATION I hereby affirm that I am licensed under provisions of Chapter 8 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. / J 811 License Number Lic.Class C D 6/ 3,303 122.-Ma C Contractor Date ��L��fS C r_1I am exempt under Sec. Plan Check fee B.&P.C.for this reason PERMIT ISSUING FEE$ �� TOTAL AL 2.22='5=D) C Q Date: TOTAL FEE C' CVIEC1; 122.50 C '2 CHA,i� olj� Signature Lr_ PLAN CHECK APPLICANT U OWNER-BUILDER DECLARATION G_ 1 hereby affirm that I am exempt from the Contractor's License Law NAME U i t for the following reason(Section 7031.5, Business and Professions r' � P h , tCOM-W01 !'�M- 5019 A2/21/96 Code): ADDRESS y6 V 1�O/ 471?6 d l-.i i.,u I, as owner of the property, or my employees with wages L as their sole compensation, will do the work and the CITY c TEL.NO. structure is not intended or offered for sale (Section 7044, Business and Professions Code). OWNER 1 I, as owner of the property, am exclusively contracting MAIL /►U with licensed contractors to construct the project (Sec- ADDRESS (}t L� tion 7044,Business and Professions Code). CITY TEL.NO. k CONSTRUCTION LENDING AGENCY - �- I hereby affirm that there is a construction lending agency for CONTRACTOR the performance of the work for which this permit Is Issued (Sec.3097,Civ.C.). ADDRESS Lender's Name CITY TEL.NO. Lender's Address STATE LIC. I certify that I have read this application and state that the above LICENSE NO. CLASS information is correct. I agree to comply with all County ordinances and State laws relating to building construction,and hereby authorize repress tatives of this County to enter upon the above-mentioned pr per for irspectio rposes. SEE REVERSE FOR EXPLANATORY LANGUAGE SI AT APPLICANT OR AGENT DATE WORKER'S COMPENSATION DECLARATION 20004f3DPW 9lQ9 • APPLICATION FOR PERMITLIME GREEN 76A3fi4C I hereby affirm that I have 4 certificate of consent to self insure, ; or a certificate of,Wo&r's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING copy thereof(Sec.3800 Lab.C.) Policy No. 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 department. (PRINT OR TYPE ONLY) ADDRESS 911/_3 Wo f7 Q LOCALITYt , Date Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE Q�� NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST. COMPENSATION INSURANCE ABSORPTION UNIT,BTU /y v�v� (This section need not be completed if the work involvod by the MAP BOOK �� PAGEC7 PARCELc Z permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO PROCESSED BY I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to BOILER,BTU become subject to the Workers'Compensation Laws. COMPRESSOR,BTU HAPPROVALS DATE INSPECTOR'S SIGNATURE Date Applicant VENTILATION SYSTEM NOTICE TO APPLICANT: If, after making this Certificate of ROUGH Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER provisions of the Labor Code,you must forthwith comply with such FINAL Z Z provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATION ACCT°4 I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT 'F 5.�� (commencing with Section 7000)of Division 3 of the Business and WALL ITEMS 3-sr Professions Code,and my license is in full force and effect. � 70 License Number Lia.Class / TOTAL 35. 7 01111. CHECK Contractor Date CHANGE �°7 C F1I am exempt under Sec. Plant Check fee ° a BAP.C.for this reason PERMIT ISSUING FEE$ j C 0000-0001 12/15/95F Date: TOTAL FEE , '7(? 3791 1 Ali 10:29u Signature G OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT (� e I hereby affirm that I am exempt from the Contractor's License Law NAME for the following reason(Section 7031.5, Business and Professions L /n (/lQ f, I � Code): ADDRESS f•Op El1, as owner of the property, or my employees with wages 5 as their sole compensation, will do the work and the CITYr TEL.NO. S/� ��>-D structure is not intended or offered for sale (Section 7044, ` Vls Business and Professions Code). OWNER C L y 1 S I �{?JI I, as owner of the property, am exclusively contracting MAIL with licensed contractors to construct the project (Sec- ADDRESS t4 A tion 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY CITY III V TEL.NO. I hereby affirm that there is a construction lending agency for CONTRACTOR w ' the performance of the work for which this permit Is issued (Sec.3097,Civ.C.). ADDRESS Lender's Name CITY TEL.NO. Lender's Address STATE LIC. I certify that I have read this application and state that the above LICENSE NO. CLASS 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 p7ty for in pection parposes. SEE REVERSE FOR EXPLANATORY LANGUAGE NAT E OF APPLICA 4T OR AGENT DATE T' 711A9ea2-QEe.tes-9/75 �APICATINOFOR MIT ' HEATING - VENTILATING - R CONDITIONING BUILDING AND SAFETY DIVISION FOR APPLICANT TO FILL IN FNEAREST NG (PRINT OR TYPE-ONLY) SS ITY- rr NO. TYPE OF APPLIANCE OR EQUIPMENT FEE ST. ABSORPTION UNIT, BTU OWNER AIR HANDLING UNIT, CFM MAIL ADDRESS V• BOILER, BTU CITY C TEL. NO."'f `t7-- �1 COMPRESSOR, BTU CONTRACTOR VENTI LATI ON'SYSTEM ADDRESS EVAPORATIVE COOLER CITY TEL. NO. FURNACE: FAU_GRAVITY STATE LIC. FLOOR BTU LICENSE NO. CLASS HEATER: SUSPENDS UNIT_ DISTRICT NO. GROUP ZONE PROCESSED BY WALL ^" C INSPECTION RECORD L G7 Z Plan check fee 25%of above. PERMIT ISSUING FEE $ TOTAL FEE PLAN CHEC APPLICANT NAME ADDRESS CITY TEL.NO. I HEREBY"ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE IS CORRECT, AND AGREE TO COMPLY WITH ALL ORDINANCES AND LAWS REGULATING HEATING, VENTI- LATING,AIR CO NOITIONING. I HEREBY CERTIFY THAT 1 AM NOT ACTING IN VIOLATION APPROVALS DATE INSPEC OR'S SIGNATURE OF CHAPTER 9, DIVISION 3, OF THE BUSINESS A!D PROFESSIONAL �• CODE OF THE STATE OF LIF NIA. 1 ROUGHL ` SIGNATURE OF PERMITTEE FINAL %,.nX. PLAN CHECK VALIDATION CK, O, CASH PERMIT VALIDATION ' cK. M.o. casH Z-- 't •.101. X6'4:3. •8 ':.:?. .;�.� 3