HomeMy Public PortalAbout5611 GOLDEN WEST AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION CE 81 C - -
I hereby affirm that I have a certificate of,consent to self CE-818 (2.80)_ �,� ����; ®0 t7 ®�` VGIt��
insure, or a certificate of Workers'Compensation Insurancg,or',' HEATIW,G-V EN.TILAT'ING-AIR =CONDITIQRhIWG'
a certified copy thereof(Sec. 3800,Lab.C.)
Policy No Company -
r. COUNTY'OF LOS ANGELES BUILDING AND SAFETY'.
Certified copy is hereby furnished.
Certified copy u Pled with the county building inspection , i �-• iBUILDING��
department _ FOR APPL"ICANT TO FILL IN - ADDRESS'
Date- Applicant"' (PRINT O`R TYPE ONL';Y);r
1�
CERTIFICATE OF EXEMPTION FROM WORKERS' NO,' STYPE OF,ARPLIANCE OR EQUIPMENT f FEE
v, w -NEAREST
COMPENSATION INSURANCE a }
(This section need not be completed if°the 'woik'involved-° ABSORPTiON_UNUT,.BTU CROSS ST
by. the`permit is fot"one hundred dollars ($106);oi less.). �" " . IDISTRICT NO PROCF,F sv U.
I certify,that in the`
performance of the work for which this (,� AI'R HANDLING UNIT,--`CFM, =
permit is issued;I,shall'not employ any person in.any manner,
so'as,to'become subject-to the Worker ',Compensation Laws _BOILIER, BTU
�� ����� g APPROVALS 'DATE INSPEC,TORSSIGNATURE,' L)
to Applicant_ c COMPRESSOR 8TU_�y_��� _,'ROUGH - d
NOTICE tO APPLICANT. If after making this Certificate of { VENTILATION SYSTEM' Z•
Exemption_you 'should',become-subject to the,,Workers' - c - � FINAL-
Coriipensation ,provisions of the-Lpbor.'Code, you must forth=
with comply with such`provisions or ,this ,•permit shall lie', _ EVAPQRATIVE COOLER- g' c, VAL-1OATi'�N
deemed revoked - - FURNACE FAUGRAVITY .
LICENSED CONTRACTORS DECLARATION FLOOR ° 'BTU
I hereby affirm that I am licensed undei,provisions oT Chapter HEATER SUSPENDED UNI -
9 (commencing with Section 7000) of Division 3 of.the'Bu`si; WALL'
ness and-Profession's Code, and my license',is in full force.and v` .
.-effect.. _
License,Nurriber � Lia Class`
Contractor' _ Date=�
I am empt ,from the licensing'requirements as I am a
licens d architect or a registered'professional-engineer Platt check fee?5%of above.
acting in my`professional,capacity (Section'7051, Bus-
iness and Professions Code).
PERMIT I$SU�NG,FEE
Lie.or Reg;'No. 'Date _w° 9 TOTAL`.FEE
f HOME OWNER-BUILDER DECLARATION -" - PLANaCHECK�APPWCANT �K _ 3,3 9,3:A
I hereby affirm 'that I am exe'mpt"from- the Contractor's_ NAME'. G' �- # o o e'a`o
License Law for the=following reason'(Sect ion,7031.5', Busi- i
ness and Professions.Code) 'AboR sS � --2'6,0 J Q'60
.'.owner of the property; will do the,work and the " '-
CITY TEL. NO.'
structure is not intended or,offered fur sale (Section,. 5 a 3 a'b Q�-
.70;44, Business,and Professions,Code,). �..• , - „- e y,
�� ;sti .' OWzNER' _�l— �( f (.7i�—Gey /` ' 10 7,O Jit_
I; as owner of-the Ooperty,•am exclusively contracting t� jt� 915^
nth.�hcensed .contractors to construct 'Ahe project, -MAIL, '
(Section404.4; Business and,Professions Code). ADDRESS:
r, CITY;, .-.�TEL.NO r�
CONSTRUCTION,,LENDING AGENCY _ . ,
- I herebyti;affirm-that there Is a`construction lending agency
for the performance, of the work for which this permit is' , CONTRACTOR ` �
'is (Sec 3097,Civ C�} Fl1Ce�+r-v ;
,Lender's Nanie `
ADDRESS �7
Lender's Address c -
;CITY i TEL. NO �/— /yi
I-certify that I have,read this applicafion and state that the STATE � L-IC.•
above mformation`is,correct I agree to comply with-all County, LICENSE NO -.� °CUASSL���/ , e
ordinances and`State laws regulating Heating, Ventilating and;
Air Conditioning, and'herebyauthorize representativesof this SEE REVERSE-FOR EXPLANATORY'LANGUAGE
County to enter upon the -above-mentioned property for r
,mspectioit purposes. +
Sm.a ure ofr_rmittee Date '" -