HomeMy Public PortalAbout4847 GOLDEN WEST AVE_Mechanical__ I _ ,
WORKERS'COMPENSATION DECcafe of TION
corse APPLICATION FOR PERMIT
�I he=eby affirm that I have a'certificate of consent to self
insure, or a certificate of Workers'Compensation Insurance, HEATING - VENTILATING AIR CONDITIONING
or a certified copy thereof (Sec. 3800, Lab. C. 76A364
E-81 REV. 10/81)
Policy No. Company J I
❑ Certified copy is hereby furnished. COUNTY OF LOS ANGELES 1 BUILDING AND SAFETY
❑ Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING F,7A
t)A GS
tion department. (PRINT OR TYPE ONLY) ADDRESS _
Date Applicant VLOCALITY- M
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE i[G::
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST.
(This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO. PROCESSED BY
the permit is for one hundred dollars ($100)or less.) '�{ tT-
AIR HANDLING UNIT,CFM v U �/(,(➢
I certify that in the performarice of.the work for which this �.
permit is issued, I shall not employ any person in any manner i1��
so as to become subject to the Workers'Compensation Laws. BOILER, BTU / /U�� APPROVALS DATE INS TOR'S SIGN/PURE
COMPRESSOR, BTU �lJ" o d ROUGH
Date Applicant �� n /
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL �c
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 i
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under,provisions of Chapter 9 SUSPENDED UNIT
'(commencing with Section 7000) of Division 3 of the Business HEATER: WALL
and Professions Code,and my license is in full force and effect.
License Number Lic. Class
/ Q
r.
Contractod�•�b�n�� Date ®/�•�%' 0
❑ 1 am exempt under Sec.
Plan check fee 9L
B.BP.C. for this reason" �
PERMIT ISSUING FEE $ 0 -�
Date:
Signature TOTAL FEE
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License aq 4 2 6 9 A
Law for the following reason (Section 7031.5, Business and NAME
Professions Code): .® ® o s ® 8
❑ I, as owner of the property, or my employees with ADDRESS ° • 4 0,5 0
T
wages as their sole compensation,will do the work and CITY TEL. NO. ° ° ° 4' 0,5��
the structure is not intended or offered for sale(Section O 3 2 1 -86
7044, Business and Professions Code).
OWNER S" "
❑ 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. N
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued CONTRACTOR
(Sec. 3097, Civ. C.).
ADDRESS 10
Lender's Name 11 J
Lender's Address CITY TEL. NOy
STATE LIC.
I certify that I have read this application and state that the LICENSE NO., CLASS Sz
above information is correct. I agree to comply with all County
ordi nces and Sto laws relating to building construction,
and hereby a u t�ri representatives of this County to enter
upo the abo eIn ioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
40 Ali
Sign re o A " I can or gent � I Date