HomeMy Public PortalAbout4845 GOLDEN WEST AVE_Mechanical__ M}. ORKE`E 'COMPENSATION DECLARATION CEA 818 C(�e0) APPLICATION FOR PERMIT
I lief lay affirm that I have r certificate of consent to self
tnsurb,`or a cerdficafb of Workers'Compensation Insurance,or HEATING-VENTILATING-AIR CONDITIONING
■certified copy thereof(Sbc.3800,Lab.C.)
Policy No. - Company
Certified copy Is hereby furnished.
COUNTY OF LOS ANGELES BUILDING AND SAFETY
.' .
Certified copy Is filed with the county building inspection
department. FOR FOR APPLICANT TO FILL IN BUILDING
Date Appllcagt (PRINT OR TYPE ONLY) ADDRESS
LOCALITY
CERTIFICATE OF EXEMPTION`FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
C'OMPENSATION INSURANCE NEAREST
(This section meed not be completed if the work involved ABSORPTION UNIT, BTU CROSS ST.
by the permit is for one hundred doUan ($100) or leas.) IAM ICT no. v eD ev
A cbrtifr,that'in the performance of the wprk-for which,this AIR HAND ING UNIT CFM—;—
permit is'Issuad, I strall not employ any person In any manner 5, V + O
so as to become subject to the Workers' Compensation Laws. BOILER BTU— ire
— IU—
APPROVALS DATE ire aaior+ATuae
Date Appllcant COMPR SSOR BTU ROUGH
y NOTICE TO APPLICANT: If, otter making this Cert)19cate of VENTILATION SY.3TEM Z
1Exemptlon, you should become subject to the Workers' FINAL
mpensatlon provisions of the Labor Code, you must forth-
th comply with such provisions or this permit shall be EVAPORATIVE COOLER VALIDATION
d�emed revoked. FURNACE: FAL GRAVITY
111 LICENSED CONTRACTORS DECLARATION FLOOR BTU
I I ereby affirm that I am licensed under provisions of Chapter HEATER: SUSPENpE_D UNIT
9 (commencing with Section 7000) of Division 3 of the Buss- ALL 212 4 a
nese and Professions Code, and my license is in full force and. )
effect. L/[/ i # • • • • 8
License Number Lia Class
Contractor Date • • 2 (1Jc O
I am exempt from the llrensing requirements as I am a
11cens6d architect or a tagistered professional-engineer Plan chock fee 25%of above.
acting In my professional capacity �S Ion 7051; Bus- PERMIT ISSUING FEE$
Iness and Professions Code).
Lic.or Res,No. Date TOTAL FEE IS • • • 2 Q 5 0
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANTY
0 1,28 _ 85
I hereby affirm that 1 am exempt from- the Codtractor's NAME
Licansq Law for the following reason (Section.7031.5, Busi- :
gess and Professions Coda): ADDRESS
1, -as owner of the property, willdo the work and the
structure Is not intended or offered for sale (Section CITY TEL. NO.
7044, Business and Professions Code).
�- u owner of the OWNER
I,
property, am exclusively coptnctlrtg
with licensed contractors to construct the project MAIL
(Section 7044, Business and Professions Code). ADDRESS
CONSTRUCTION LENDING AGENCY CITY TEL.NO.
'1 hereby affirm that there Is ■ construction lending agency
for the performahce of the work for which this permit is CONTRACTOR
issued (Sec. 3097,Civ.C.).
Lender's Name ADDRESS :
Lender's Address CITY TEL. NO.
I certify that I have iroad this application and state: that the STATE LIC.
above information is correct.I agree to comply with all County I E CLASS
ordinances and State laws regulating Heating. Ventilating and
Air Conditioning,and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
County to a ter upon the above-mentioned property for
bis tion p ores
JC/
Signature o ttee Date o