HomeMy Public PortalAbout4851 GOLDEN WEST AVE_Mechanical__ SCOMPENSATION°ECLARt to eA3WDPW 9'� APPLICATION FOR PERMIT LME GREEN
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I hereby affirm that I-have a oertlfloate of consent to salt Insure, 7
or a certfflWte oLworkers Compensation Insurance, or a oerttfled HEFTING -VENTILATING -AIR CONDMONING
copy thbreof(Sec.3800 Lab.C.)
Policy No.'---_—Company COUNTY OF LOS ANGO FR DEPT OF.PUBLIC WORKS BUILDING AND SAFETY DIV.
❑ CerdW copy Is hereby fumSahed.
❑ Carttned copy Is flied with the oounty buMng lrope tion FOR APPLICANT TO FILL IN a
MLDIW
(PAINT OR TYPE ONLY)
LOCALITY
Dem PA
Ak-n NO. TYPE OF APPI-MICE OR EQUIPMENT FEE
CERTIFICATE OF E IDAPTfON FROMWORKEi8' gBOgg gT• �'
COMPENSATION INSURANCE ABSORPTION UNIT BTU
(This seotton need not be oompMted If the work Involved by the YAP BOOK PAC7ED� PAACl-Lt603
permit Is for one hundred dollars($100)or Mee.) AIR SUNG UNIT CFM,
osmscr No. rnocse®BY
I oertlfy 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 DOI LEP,BTU
beoome subject to the Workers'Compe MU G /0
Daft /— r APP"Au eo
DATE sarrO"seroma
VEMRATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROLKiR 42
Exemption,you should beooms sub)ect to the Workers' Comperaatlon EVAPORATrVE COON
provisions of the Labor Code, you must forthwith comply wfth such FINAL
proylelona or this permit shell be deemed revoked. FURNACE FAU aRAvrry to Q V LIDATION
L iCa 1 CONTRACTORAR
S DECLATION I FLOOR BTU
I hereby affirm that I em Iloensed under provisions of Chapter 9 SUSPENDED UNIT '
(commencing with Section 7000) of DMalon 3 of the Business and HEATER: WALL
Professions Code,and my licenyse/Is In full foroe and effect.
Lk»rrse Number Lk-_Class
r '
7' WXI-r
a T
Dene Plan check fee �30-3 115.5,3 S
I am exempt under Bea 1 1 TErS a:
B.sP.C.for fhb reason PERMIT ISSUING FEE E - TIJTh� 1 lir�I -i i
- c0
Date:
TOTAL FEE C�ECX 115.T E
sbnohire
OWNEFI�-BUILDEA DECLARATION PLAN CHECK APPucANT t .1213—
Z
I her"affirm that I am exempt from the Contractors License Law NAME ' rl7�tJL
for the following reason (Section 7031,6, Business and Professions
Code): ADDRESS
❑ I, as owner of the property, or my employees with wage-@ 1 ,O +�( t�
as their sole compensation, will do the work and the CITY TFL p63 NO. 1 AM u •Jr
structure Is not Intended or offered for sale (8ectlon 7044,
Business and Professions Code). OWNER
❑ I, as owner of the property, am exclusively contracting YAC
with licensedcontractors to construct the project (Seo- ADDRESS
tion 7044, Bual non and Professions Code).
CONSTRUIO
CTN LENDING AGENCY CfTY TEL
I hereby affirm that there Is a construction lending agency for CONTRACCTOR ,
the performanoe of the work for which thle permit Is Issued
(Sec.3097,Civ.C.).
ADDRESS /
�L ra
Lenders Name r
CITY
TEL NO.
Lenders Address STATE LIC. O
I certify that I have read this application and state that the above LICENSE NO. CLASS
information Is correct I agree bo comply with all County ordinances
and Stade laws relating to buIIdt ng conaLuot ow,and her"authortze
of this Gouotyto enter upon the above-mentioned
props r Impact p SEE FOR EXPLANATORY LANGUAGE