HomeMy Public PortalAbout5459 GOLDEN WEST AVE_Mechanical__ WfACOMPENSATION DECLARATION APPLICATION FOR PERMIT
� hep,�'6f�dirm m that I have.a certificate of consent to self
ins8re, or a cgificat6 of'Workers' Compensation insurance, HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof (Sec. 3800, Lab. C.) 76A364C
CE-818(REV. 10/81)
Policy No. Company
Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
El Certified copy is filed with the county building inspec- FOR APPLICANT.,TO FILL IN BUILDING,,5111',� > >r„n
tion department. ADDRESS
(PRINT OR TYPE ONLY)
Date Applicant LOCALITY -772�Frpe 4=
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
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. PROCESS BY
the permit is for one hundred dollars (;100)or less.) n
AIR HANDLING UNIT, CFM jvgr
I certify that in the performance of the work for which this ` f
permit is issued, I shall not employ any person in any manner
so as to become subject to the Work rs'Com soli n Laws. BOILER, BTU APPROVALS DATE NS ECTOR'S GN TURE
COMPRESSOR, BTU �Q 0 ROUGH
Date Applicant .
NOTICE TO APPLICANT: If, after kaking t is Certificate of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor.Code, you must forth- EVAPORATIVE COOLER If A ATI N
with comply with such.provisions or this permit shall be
deemed revoked. FURNACE: FAU —GRAVITY a
LICENSED CONTRACTORS DECLARATION FLOOR BTU Gf
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT'(commencing with Section 7000) of Division 3 of the Business WALL
and Professions Code, and my license is in full force and effect.
O
License Number Lic. Class ► tJ
Contractor Date O
❑ I am exempt under Sec. W
Plan check fee
B.&P.C. for this reason
Date: PERMIT ISSUING FEE $ 3' #;2 3 Ll 4,3 Z
TOTAL FEE /� I o - 30.5
Signature
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License �.—�� 1 1 v
Law for the following reason (Section 7031.5, Business and NAME
Professions Code):
❑ I, as owner of the property, or my employees with ADDRESS iJ ,
wages as their sole compensation, will do the work and
he structure is not in
or offered for sale(Section CITY TEL. NO.
7044, Business and Professions Code).
OWNER �
I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec- MAIL
tion 7044, Business and Professions Code). i ADDRESS
CONSTRUCTION"LENDING AGENCY CITY TEL. NO.
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
Lender's Name
CITY TEL. NO.
Lender's Address
STATE LIC.
I certify that I have read this application and state that the LICENSE NO. CLASS
above information is correct. I 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 ab ve-me ned property for inspection purposes. SEE REVERSE'FOR EXPLANATORY LANGUAGE
Signal re of Appli ant or Agent Date _
i