HomeMy Public PortalAbout5606 GOLDEN WEST AVE_Mechanical__ pAKER'S COMPENSATION DECLARATION 20-0046 DPW 9,69 APPLICATION FOR PERMIT �� E GREE14:1
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I hereby affirm'�lhat I have a certificate of consent to self insure,
or a certificate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING
copy thereof(Sec. 3800 Lab. C.)
P❑oliity No. ' Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS UILDING AND SAFETY DIV.
Certified copy is hereby furnished.
ElCertifiedcopy is filed with the county building inspection FOR APPLICANT TO FILL IN
BUILDING
"
department. (PRINT OR TYPE ONLY)
Date Applicant LOCA &446U4
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
CROSS ST. Ir
COMPENSATIONINSURANCE ABSORPTION UNIT,BTU
(This section need not be completed if the work involved by the ASSESSOR
MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU
become subject to the Workers'Compensation Laws.
COMPRESSOR,BTU DO
— IICan APPROVALS DATE INSPECTOR'S SIGNATURE
Date A
PP VENTILATION SYSTEM
NOTICE TO APPLICANT: If, Imter making this Certificate of ROUGH _ -7
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code,you must forthwith comply with such FINAL 7_ _
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION � FLOOR BTU rrr7 VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED -UNIT
(commencing with Section 7000) of Division 3 of the Business and WALL
Professions Code, and my license is in full force and effect. -
License Numb erLic.Class
a_
Contr0
❑ I am exempt under S Plan Check fee
Q
B.&P.C.for this reason PERMIT ISSUING.FEE$ 3 p O
Date: TOTAL FEE W
Signature (-
PLAN CHECK APPLICANT
OWNER-BUILDER DECLARATION Z
I hereby affirm that I am exempt from the Contractor's License Law NAME
for the following reason (Section 7031.5, Business and Professions »
Code): ADDRESS
❑ I, as owner of the property, or my employees with wages
as their sole compensation,•will do the work and the CITY TEL.NO. :L_,µ ="
structure is not intended or,offered for sale (Section 7044,
_T.y
Business and Professions Code). OWNER
❑ I, as owner of the property, am exclusively contracting Alpt
MAIL " eyy +$` # } '
with licensed contractors to construct the project (Sec- ADDRESS = a
tion 7044, Business and Profess ions.Code). / NE
;- CK -- i 7.
CITY6�-- 4 Lp. EL.NO. - .: ir:•
CONSTRUCTION LENDING AGENCY a
hereby affirm that there is a construction lending agency for CONTRACTOR , rIF9t7C
the performance of the work for which this permit Is issued
(Sec.3097, Civ.C.).
ADDRESS
Lender's Name
CITY TEL:NO. -i
Lender's Address
STATE // LIC. - •
I certify that I have read this application and state that the above LICENSE NO. ,� D, CLASS 7�
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 above-mentioned
propert for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
U E OF AB ICANT OR AGENT DATE