HomeMy Public PortalAbout5528 GOLDEN WEST AVE_Mechanical__ t; ly affi-rm that
COMPENSATION DECLARATION APPLICATION FOR PERMIT
-J herei5y affirm that 141ave a certificate of consent to self
insure, orta2ertificate 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
❑ Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDIN *.-��(y
Tion department. (PRINT OR TYPE ONLY) ADDRE S z1
Date Applicant LOCALITY T ` Cl
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE 1
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. PROCESSED
the permit is for one hundred dollars ($100)or less.)
I certify that in the performance of the work for which this AIR HANDLING UNIT, CFM 0
permit is issued, I shall not employ any person in any manner
BTU
so as to become subject to the Workers'Compensation LOWS. BOILER, APPROVALS DATE INS TOR'S SIGNATURE
Datq/
j "'e�Applicar,�
v t COMPRESSOR, BTU .36 0✓" �V V ROUGH a,
.
NOTICE TO APPLICANT: If, after ma ing this Certificate of VENTILATION SYSTEM FINAL
Exemption, you should become "subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VAL DAT ON
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU GRAVITY o
LICENSED CONTRACTORS DECLARATION -21 FLOOR BT6L=O 0 Q
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,andel my license is in full force and effect. �)
License
�NNu�n, 3V /2— Lic. Class �4y 120 V , ki
09
CoN#rAETor Date/ `7 7 O
❑ 1 am exempt under Sec. .228 0.9.ll A MJ
Plan check fee
B.BP.C. for This reason' # e o o, �e 8
PERMIT ISSUING FEE a m
Date: TOTAL FEE ° ° 7 `a 0 0
Signature
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT e o o 7 a 0 0 5
I hereby-affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and NAME 9`8 7
Professions Code): Q 0
❑ I, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and
the structure is not intended 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). 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.).
LDDRES�SLender's Name TEL.
Lender's Address �7 /
I certify that I have read this application and state that the LICENSE NO.c � b CLASS - G
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
pont bove-men ed property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Dote