HomeMy Public PortalAbout5405 GOLDEN WEST AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION CE 81 �
I hereby affirm that I have a certificate of consent to self 76 " 6C 4 (2-80) !r-\IT" P L� C Gil T�OO �V FOR lr"E R Il�%l}� Il
insure, or a certificate of Workers'Compennation Insurance,or
Tae
fi ' ccpy thereof(Sec. 3800,1 ab. C.)
Company—�1i COUNTY OF LOS ANGELES / t` � BUILDING AND SAF E7Y
ertified copy is hereby furnished.
ertified copy is filed with the county building inspection BUILDINGpartment. FOFi APPL9C,�fllT TO FELL 9fil Applicant
(PRINT OR TYPE ONLY) ADDRESS
LOCAUT `/'�
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE L!_
COMPENSATION INSURANCE NEAREST }
(This section need not be completed if the work involved ABSORPTION UNIT, BTL CROSS S.T. 0
by the permit is for one hundred dollars ($100) or less.) DISTRICT NO.. PROCESSED 0' C)
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 mannerPj SO
so as to become subject to the Workers' C -nensation Laws. BOILER, BTU 14 0 r—
APPROVALS DATE INSP ECTOR'S.SIGNATURE U
LLI
Date Applicant(�. J\`-- - , �, fA
COMPRESSOR,BTU ROUGH
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM '' Z
Exemption, you should become subject to the Workers' FINAL
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—
LICENSED
RAVITY LICENSED CONTRACTORS DECLARATION FL ^^ BTU
I hereby affirm that I am licensed under provisions of Chapter I HBA c SUSPENDED UNIT ` T
9 (commencing with Section 7000)of Division 3 of the Busi-. WALL J
ness and Professions Code, and my license is in full force and
effect.
License Numbe�_ _ Lic.Class
Contractor_e _ ' to
0 I am exempt from the licensing requirements as I am a
licensed architect or a registered professional, engineer Pian check fee 25%of above.
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code).
Lic,or Reg.No. Date TOTAL FEE
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from- the Contractor's NAME
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): ADDRESS
I, as owner of the property, will do the work and the :9 .5 1' 1 A
structure is not intended or offered for sale (Section CITY TEL. NO.
7044,.Business and Professions Code). OWNER . `:N
� �� � o b*0 0 0
- Z
I, as owner of the property, am exclusively contracting 2,0,a 2,7 0 0
with licensed contractors to construct the project MAIL t J
(Section 7044, Business and Professions Code). ADDRESS — � _ _ o'o o2-7,00-5
CONSTRUCTION LENDING AGENCY CITY TF'
I hereby affirm that there is a construction lending agency ' 1 Q '1 3,—8,1
for the performance of the work for which this permit is CONTRACTOR
issued(Sec. 3097,Civ.C.).
Lender's Name ADDRESS yl
Lender's Address CITY TEL.NO.
I certify that I have read this application and state that theSTATE\..� ` -----.��—��� ''/\�\ LI'C.
above information is correct. I agree to comply with all County LICENSE NO. 4 �1 --CLASS ���
ordinances and State laws regulating Heating, Ventilating and
Air Conditioning,and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
county to enter un the above-mentioned property for
Inst�ction p�_ettepe"
ureofDate
76A364E IC® 818A) 9/77 APPLICATION FOR PERMIT
HEATING - VENTILATING - AIR CONDITIONING
Baty of ''emple ci.ty U0. r 2"3"
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIV 1drK
FOR APPLICANT TO FILL IN BUILDING1 y
(PRINT OR TYPE ONLY) ADDRESS C',,0�,den .'or L 1,ot
LOCALITY °.'CP,in10 i.'�.ty
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
NEAREST
CROSS ST.
ABSORPTION UNIT, BTU p
OWNER G� :� 6L
AIR HANDLING UNIT,CFM MAIL4'r}C �; e .+�t+"lt'
ADDRESS J
BOILER,BTU CITY AXwcL,a TEL.NO.
COMPRESSOR, BTU 1{ CONTRACTOR BalMee Htg• & AA;
VENTILATION SYSTEM ADDRESS 12 North liom i
EVAPORATIVE COOLER CITY rIzumo. TEL.NO. 337-6732
FURNACE: FAUX_GRAVITY STATE 7 r, LIC. ,ry hr
FLOOR BTU n r3 " LICENSE NO. 2✓ -� CLASS ''-2
a_^.� 1
HEATER: SUSPENDED UNIT- DISTRICT NO. GROUP ZONE PROCESSED BY
WALL
O.
O
INSPECTION RECORD V
17♦I
..i
W
OC
Plan check fee 25% of above.
PERMIT ISSUING FEE$ •' 0
TOTAL FEE ✓ •t? w
PLAN CHECK APPLICANT
NAME
ADDRESS
CITY TEL.NO.
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND
STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL
ORDINANCES AND LAWS REGULATING HEATING. VENTILATING, AIR
CONDITIONING.
I HEREBY CERTIFY THAT I AM NOT ACTING IN VIOLATION OF APPROVALS DATE INSPECTOR'S SIGNATURE
LICHAPTER 9, DIVISION 3, OF THE BUSINESS AND PROFESSIONAL CODE
HE STATE OF CALIFORNIA. ROUGH
km
ATURE
ERMITTEE ' ..../ FINAL
PERMIT VALIDA
PLAN CHECK VALIDATION CK. M.O, CASH I N cK M.o cns
i • e •