HomeMy Public PortalAbout5303 GOLDEN WEST AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
I hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
CE-81
or a certified copy thereof (Sec. 3800, Lab. C.) C
CE 818(REV. 10/81)
Policy No. Company
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 department. ADDRESS oe C>LrN ` J),S
(PRINT OR TYPE ONLY)
Date Applicant LOCALITY L-r /1rP�
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE y l Cl-,-60'./
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST.
ABSORPTION UNIT, BTU DISTRICT NO. PROCESSED BY
(This section need not be completed if the work involved by
the permit is for one hundred dollars (;100)or less.)
AIR HANDLING UNIT, CFM
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 become subject to the Worke 'Comp atl L S. BOILER, BTU APPROVALS DATE INSPECTOR'S SIGNATURE
Date I-� Applicant COMPRESSOR, BTU ROUGH ,
NOTICE TO APPLICANT: If, aft making this Cer' tate of VENTILATION SYSTEM FINAL rt
Exemption, you should bec subject to th Workers'
Compensation provisions of t Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION
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: SUSPEND D UNIT
'(commencing with Section 7000) of Division 3 of the Business WALL
and Professions Code,and my license is in full force and effect.
License Number �6 Lic. Class IC ,
r r��1i92
Contac ,S' Date ^JJ- SJ
ls
❑ I'am exempt under Sec. JIM
Plan check fee
B.&P.C. for this reason
Date: PERMIT ISSUING FEE $
Signature TOTAL FEE
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and NAME , a' 042 7J A
Professions Code):
❑ I, as owner of the property, or' my employees with ADDRESS
#'o,a a a o'g
wages as their sole compensation,will do the work and CITY TELNO.
the structure is not intended or offered for sale(Section 2.o Io,2 Q 50
7044, Business and Professions Code).
OWNER rl / I , ) 2O,lr?O0
❑ I, as owner of the property, am exclusively contracting /` J o.0 0
with licensed contractors to construct the project (Sec- MAIL
tion 7044, Business and Professions Code). ADDRESS Go e- ,cj " wrTs I 0A I .r 1 —814
CONSTRUCTION LENDING AGENCY CITY ` Cell TEL. NO. L�� �
I hereby affirm that there is a construction lending agency for ,
412
the performance of the work for which this permit is issued CONTRACTOR' 7/�O `� ju'
(Sec. 3097, Civ. C.).
ADDRESSiq
d h./ .� .
Lender's Name
CITY Vv f�/ TEL. NO.
Lender's Address
STATE [�. LIC.
I certify that I have read this application and state that the LICENSE NO. 7 6 CLASS ^
above information-is correct. I agree to comply with all County
ordinances and State laws relating to building construction,
and hereby authorize repre ntotIves of this County to enter
aa
up o aboverepJjone ioperty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
ature ofApplicant or ent Date -