HomeMy Public PortalAbout5616 GOLDEN WEST AVE_Mechanical__ WORKER'S COMPENSATION DECLARATION DPW
76A364APPLICATION FOR PERMITLIME GREEN,,
76A364C '
I hereby aft.irm that 4 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.)
Policy No. Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
Certified copy is hereby furnished.
❑ Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN gppREs3
department. (PRINT OR TYPE ONLY)
Date Applicant _ LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
CROSS ST. 1117
COMPENSATION INSURANCE
ABSORPTION UNIT,BTU ASSESSOR
(This section need not be completed if the work involved by the MAP BOOK ���1P PAGE PARCEL',z��2
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is issued, 1 shall not employ any person in any manner so as to BOILER,BTU
become subject to the Workers'Compensation Laws.
COMPRESSOR,BTU 60= 1710'
Date � A IICBM APPROVALS DATE INSPECTOR'S SIGNATURE
Pp VENTILATION SYSTEM
�� r�
NOTICE, TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL Z—/��7
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY ^ VALIDATION
LICENSED CONTRACTORS DECLARATION FLOOR BTU 0 Gi
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED—UNIT—
(commencing
USPENDED UNIT(commencing with Section 7000) of Division 3 of the Business and HEATER: WALL
Professions Code,and my license is in full force and effect.
License Number rUJ�CJ `v Lic.Class_ o
Contractor i Date _ 0
❑ Plan check fee 330 1.4t,.15 0
I am exempt under Sec..
BAP.C.for this reason PERMIT ISSUING FEE$ 1.ITEMS 0
Date: TOTAL FEE ` .OTAL. 126 = 15 W
Signature PLAN CHECK APPLICANT r•.:�'IECK - 126.1a a-
OWNER-BUILDER DECLARATION CHANGEiCHANGEHL�Ar�
E .00I hereby affirm that I am exempt from the Contractor's License Law NAME '
for the following reason (Section 7031.5, Business and Professions
Code): ADDRESS5 ft f
EJ 1, as owner of the property, or my employees with wages L11303J-13001 4/ 6/73
as their sole compensation, will do the work and the CITY TEL.NO.
structure is not intended or offered for sale (Section 7044, 9 I72 1 Ai F i`'fie
Business and Professions Code). [ADDRESS
WNER
❑ I, as owner of the property, am exclusively contracting MAIL
with licensed contractors to construct the project (Sec-
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY TEL.NO
I hereby affirm that there is a construction lending agency for CONTRACTOR
o '
the performance of the work for which this permit Is issued
(Sec.3097,Civ.C.). -
ADDRE
Lender's Name
CI TEL.NO.
Lender's Address T09'
I certify that I have read this application and state that the above LICENSE NO. j�O CLASS
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
property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATURE OF APPLICANT OR A ENT DATE