HomeMy Public PortalAbout5525 GOLDEN WEST AVE_Mechanical__ „�WORKERS' COMPENSATION DECLARATION APPLICATION FOR PERMIT
ereby affirm*thSt I�h(5v'e a certificate of consent to self
insure, or.q certificate of Workers' Compensation Insurance, 76A364C HEATING - VENTILATING - AIR CONDITIONING
ora certified copy thereof (Sec. 3800, Lab. C.)
CE-818(REV. 10/81)
PolPolicy No. Company
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified)py�aQ"ereby furnished.
Certified copy is.filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING(PRINT OR TYPE ONLY) �
tion department. ADDRESS 6;/_,4
Date Applicant /LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE e
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSSST. jjrDll�twJq
(This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO. ,P OCESSED BY
the permit is for one hundred dollars ($100)or less.) ,rl
AIR HANDLING UNIT, CFM
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers'Compensa 'on Laws. BOILER, BTU APPROVALS DATE Iys CT S SIGN TURE
Date✓r-Z3 Applicant i COMPRESSOR, BTU s ROUGH
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL r
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER V &TIO NAI
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU_L—GRAVITY /)�
LICENSED CONTRACTORS DECLARATION FLOOR BTU V”u a o (�'
hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT
(commencing with Section 7000) of Division 3 of the Business HEATER: WALL
and Professions Code,and my license is in full force and effect.
`iCL
Licens'b Number Lic. Class , U
t�
Contractor Date O
V
I am exempt under Sec. E,y
Plan check fee �.
B.&P.C. for this reason PERMIT ISSUING FEE-$
Date: TOTAL FEE S 7 z 9 6 5 2 A
Signature.
OAER'-BUILDER DECLARATION PLAN CHECK APPLICANT #,a o oto o 8
1 hereby affirm that I am exempt from the.Contractor's License '0 0
Law'for„the following Treason (Section 7031.5, Business and NAME 3 7 5
' p �'p N i^C// ►
Profestions Co'cfe')�'
1;71
la =
I, as owner of The property, or my employees with ADDRESS 3 C�a�) �'� w S�i ''o 0 0 3 '] 5
wages as their sole compensation,will do the work and CITY / G TEL. NO.
the structure is not intended or offered for sale (Section �����;`�. f L' , Z. Z1,3 �i �/� 2- Jr 2 3=8 8
7044, Business and'Professions,Code).
OWNER Q
❑ I, as-owner of the:property, am exclusively contracting
with 114ensed_,contra&ors to,construct the project (Sec- MAIL
tion 7044,Business and Professions-Code). 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 she above-m ed prop rt for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date