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Home My Public Portal About5133 GOLDEN WEST AVE_Mechanical__ WORKZFkS'COMP);NSATION DECLARATION- CEA 818C(2.80)r �.�IS. �r�� ®tl�1 �0A P 8 II�%N T I herel� m th-4t I' have a certificate of consent to self,_ msp,'K;o'MV1N_riific,,te of•Wvrksrs'Compensation,Insurance.or'` ' p- EATING-VENTILATING-AIR CONDITIONING a certified cdpy ther'eof•(Sec. 3860,Lab.C.)' Policy tioP,28849-'Company—Zen tYtr—�---- Q Certified sapy is hereby turnrshed COUNTY OF LOS ANGELES ... BUI LDINIq AMD SAFETY rx,. Certified copy 4filed wit 0 , .t v .ding inspection' BUILDING -dpp�rt iteif FOR,APPLICANT TO FILL IN Date � l��Applieaii^:� _ ;(PRINT OR_-TYPE ONLY) _ - ADDRESS 51'33_N_. Go1_denwestt t., LOCALITY CtRTI-n' ATE OF E�°nNIPTJON FR�M Y'QRKERS' NO.' TYPE OF APPLIAtJ'CE OR EQUIPMENT FEE T_emp.I,e—Cl-ty compels,•. ION INSUR 'E NEAREST This-se CROSS ST ' ( C#ipn, need SIOt�CS6 completed,if the Worlt'iriVOlYed ABSORPTION UNIT, PTU � � O• by the perrr;it'is fart ene-•hundred dollars ($100) Or less.) OISTRICT NO., PROS S. Day U AI R'HANDLING UNIT,'CFM I cii`.rtify'that in the,perforkianee of the Aiork'for which this /I;X permit is.#5susd, I-shall nof'employ apy,person in any manner , - 4 vvv (((JJJ O so d to become sabred"to the Workers' Compensation'Lavvs.'- BOILER, BTU •* APPROVALS DATE INSP CT SSIGNATURE` - W Applieznt ` L 1• COMPRESSOR,BTU 3--ton 10 ' 0� ROUGH' ��y� �� rn NOTICE TO APPLICANT. If, after making this Certificate of ti " ' VENTILATibN SYSTEM' z' Ekemption, ''you should become- subject,to the Workers' FINAL_ __ r _ Campensatrgn-provisio7$'of the Labor Code, you must forth- EVAPORATIVE,COOLER V LIDATION tvitl z dimply' w(lh such provisions: or "this ,permit shall be' deemed revnkefi:; " FURNACE:' - FAUX"—.0 Q"V/ITY 'Ll-CEtNSED CON-ItI ACTORS DECLARATION 1r FLOOR -BTU-8-OM 10 •00, I hereby affirm that I am licensed underprovisrdns'of Chapter - HEATER SUSPENDED .;- UNIT 9-(eominehcing with Section 7000)of Division,3 of the Busi- WALL new and Professions Cdde, and my license is ut full,forcc and'; „ effete. 2217,51 C 2 C u. - T ;21 2 `a 1 A '. License?"-itnizict:,�-t ier_ Lir, Class - ' ContracDate �J Q5 Q' I rhe licensinrequremenfsits Iam'a ;licris registered;prpfessional engineer plan check fee 25%of above; - .; • • 3 Q 5 acting-in my_professional capacity (Section•,7051, Bus- Mess and Professions Code). PERMIT ISSUING'FEE00 10 5C i Lie,'or Re No. Date TOTAL FEE 12 2 Q $4' - 305U HOLE OWNER'�tJILDER DECLA32AT10N PIAN CHECK APPLICANT I hareby,,affiTm'that'I aur exenlpt from- the Gontractor's NAME a -License Law for thefollowing reason (Section 7031.s, Busi ness and Professions Codz): ,.' ADDRESS ° ET I, as div °er•of the property, will do'the'work and the - structUre�is not intended or offered far sale (Section CITY ,. " ` TEL NO.,_ - - 704$, Business-add Profe, ions Code),, - I, as owger`fit the re ert am exclusiveC contracting OWNER - p n y, y 9 K:—Okamoto y • "�` with licensed'cdtitraCjq s to construct the :project MAI,L^ (Section 7044,'d4 tress and Professions Code). ADDRESS 51_3 3__'_N,_G-QZdenwesa � << CONSTRUCTION LENDING AGENCY CITY . TEC'.NO. _ . ] hereby affifm that there, is a constrrlction tending agency; -Temple_C-i,ty -' 2-85-5-7-06, -_� •r , :fe}i t1ile- ptfrforntarice pf the`Work for which' this permit is CONTRACTORBryant Heat�2, & A C issued (See,13097,CLw"C.). , d Lander shame �� ADDRE55� "1350', — E La S T1. ll - na SDr_. 1,endpr's Address - - _ti CI , , I- T•• TEL-,NO . S an_Gabr_-i e l 2-8 6--1-14'1 I certify that i have ae2d'this application and stats that the STATE LIC • above information_is ea�%ect;.I-agree tv comply with all County., ICENSE NO Z Z 1 7 51 i CLASS CZ-0" ordinpnCes and State Taws regutat►ng-HeSttng,V@ntilating ands r' v Air ^_ iditioRing, and hereby authorize representatives of this, SEE REVERSE FOR EXPLANATORY LANGUAGE County to -ter upon the above-intentioned properly 'for Sh,r .ureofPermit' pate - CORKERS"COMPENS'ATION DECLARATION APPLICATION 'FOR" PERMIT ` I hereby 6ffrrm that I have a certificate of consent to self insure, or a ceraificate of Workers' Compensation Insurance,. K - HEATING- - VENTILATING - AIR CONDITIONING CE-818 or a certified copy thereof (Sec 3800, Lab'C )// (REV 10/81)- Policy NQ/ -3 5U ompony�/pp CE 818 j!7i ED ilQ12 Certified copy is Hereby furnished COUNTY OF LOS ANGELES BUILDING AND SAFETY �( Certified copy is filed with the county,building Inspec- FOR APPLICANT TO FILL IN- BUILDING tion departmerlt c (PRINT OR TYPE ONLY) ADDRESS r- Date - Appllc LOCALITY nr NO TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST J_A- COMPENSATION INSURANCE CROSS ST (This section need not be completed if the work Involved by ABSORPTION UNIT, BTU DISTRICT NO PROCESSED the permit is for one hundred dollars (S100)or less.) �` D I certify that in the performance of the work for which this- AIR HANDLING UNIT, CFM permit Is Issued, I shall not employ any person in any manner so as to become subject to the:Workers'Compensation,Laws BOILER, BTU APPROVALS DATE PE R'S SIGNATURE Date Applicant COMPRESSOR, BTU ROUGH NOTICE TO APPLICANT If, after making this Certificate of , VENTILATION SYSTEM FINAL Exemption, you should become subject to the Workers' Compensation provisions ofIthe Labor Code, you must forth- EVAPORATIVE COOLER VALIDAT N- with comply with such'provisions or this permit shall be deemed revoked FURNACE FAU-GRAVITY' LICENSED,CONTRACTORS DECLARATION FLOOR BTU I hereby,affirm that I am licensed under provisions of Chapter 9 HEATER SUSPENDED •UNIT (commencing with Section 70DD)•of Division 3 of the Business WALL and Professions Code,and my license is in full force and effect _- /) d ka�x License Number f J 4 r1 2�J{�C Class (J ►_ V (� / OC Contractor T j.-k•I AKA F&Date r U ❑ I am exempt under Sec W Plan check fee B&P C for this reason N PERMIT ISSUING FEE $• Date , Signature I • -1 TOTAL FEE �9.3&6 OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT I hereby affirm that I am exempt from the Contractor's License \ 0 2 a 5 0 Law for the following reason (Section%7031 5, Business and NAME Professions Code) n ADDRESS S° 0 2 Q 5.0 ❑ 1, as owner of the property, or'my employees with ��' wages as their sole compensation,will do the work and N - o4, 1, `y'8 8 the structure Is not intended or offered for sale(Section CITY I' TEL NO �s 7044, Business and Professions Code) ❑ I, as owner of the property, am exclusively contracting, OWNER-MAIL • with licensed contractors to construct the project (Sec- tion'•7044, Business and Professions Code) ADDRESS T CONSTRUCTION LENDING AGENCY CITY /J - 7- -TEL NO i t.•1 hereby affirm that-there is a construction lending agency for the performance of the work for which this permit is issued CONTRACTOR' ' (Sec 3097,, v C ) , ADDRESS - K =.-- Lender's Name CITY Ar TEL NO `J c� �4 47, S� _ Lender's.Address STATE /, `- 1 I certify that I have read this application and state that the (CENSE NO . 2vs�' CLASS - -- . . above information is correct 1 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 entioned property for nspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent rDote- '" - .1 - . • r