HomeMy Public PortalAbout5626 GOLDEN WEST AVE_Mechanical__ WORKER'S COMPENSATION DECLARATION 20-0046 DPW,9/89
' 76A364C APPL'ICATIO•N FOR PERMIT:;LIME_ GREEN
haretSy'affir�m that I have a certrficate.of consent to self Insure, ,
or a cerfifice of-V,�orker s Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING',,
copy thereof(Sec'3800'Lab C)
'Policy No Company ��V' COUNTY OF LOS ANGELES - DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
r
�'• '..Certified copy Is hereby.furnished • ` '
Certified co is filed with the count building inspection FOR APPLICANT'TO FILL IN BUILDING '
departmenlpy ?' y g, p (PRINT OR TYPE ONLY) ADDRESS 2 �'Ja�, vr '`jfl •�T'
{"
LOCALITY 1 ,
t 'Date 1 I Appticant � '�7i `��' NO TYPE OF APPLIANCE OR EQUIPMENT FEE
NEAREST l ,��� "• c,w
CERTIFICATE OF,EXEMPTION FROM WORKERS' CROSS ST /_/ 1
COMPENSATION INSURANCE a ABSORPTION UNIT,BTU 'sem '` - �• '
(This-section need not be completed if the work Involved b the ASSESSOR,
(, P Y � O �,MAP BOOK' _ PAGE -PARCEL
permit,ls for one hundred dollars($100)or less.) r AIR HANDLING UNIT,CFM o�
DISTRICT NO PROCESSED BY
:'certify-that in the performance of the work for which this permit i
',- Is'issued, I shall not•employ any person In an manner so as to
Y BOILER,BTU h
become subject to the Workers'Compensation'Laws ✓� Q
_ COMPRESSOR,BTU •- - •t"
v .
.APPROVALS .DATE INSPECTOR'S SIGNATURE ,
Date " ^ Applicant - VENTILATION SYSTEM
NOTICEITO APPLICANT If, after'makmg,this Certificate of _ :•{ ROUGH - =
') Exemption;you,should'tiecome'subject to°the Workers' Compensation EVAPORATIVE COOLER
-,3proyisions of the Labor Code, you must forthwith comply with such215 FINAL,
provisions or this permit shall be deemed revoked 'FURNACE`, FAU ` r
'y LICENSED CONTRACTORS DECLARATIONFLooR BTU DOO VALIDATION ,
1 hereby affirmthatI amdioensed•,under provisions of Chapter"9 HEATER SUSPENDED 'UNIT
,(commencing with Section;7000)'of Division 3 of the Business and WALL
Professions Code,,and my'licennsse'is in full force and-effect u•
License Number /- �"'— LIc Class ��
ANT.ir n ,a
Contractor• r +� �' 'I �A� ' Date 1�r I - L 1 126 '7 3 V
am exempt under Sec' Plan Check fel 1 , t
j, ITEMS ' , o
B&P C for this reason PERMIT ISSUING FEE$ t
Date TOTAL FEE � .� , , CHECK - 126.70 W
0-
Signature
co
PLAN CHECK APPLICANT "
OWNER-BUILDER DECLARATION 9 " ' rt^ CHANGE =00a,z
I hereby affirm that I am exempt from ttie Contractor's License Law ° NAME r
for the' following reason (Section 7031 5„Business and Professions 7
hn-�WV1 4�� _170
Code) 4
-, ADDRESS _ _ + '' _ ' 0000 V 5J 70 _
I, as owner of the•property,.or-my employees with,wages j L�� 1 F�� cenry
as their sole compensation, will ,do the work and the CITY TEL NO' OLt! Vv
° structure is not Intended or offered.for,sale (Section 7044, +' w
Business and Professions Code) OWNER jb 0,A-�L-
I', as owner of the property; am exclusively contracting' MAIL
with'hcensed contractors"to construcbthe project (Sec-, ADDRESS
tion 7044, Business and'Profe'sslons:Code) CITY TEL NO , O
i LlCONSTRUCTIOWLENDING AGENCY
I'hereby affirm that there Is aconstruction lending agency for - °• v '
tKe performance of,the-work for which-this permit Is Issued CONTRACTOR ,:F_ ••;? . 7'
(Sec,3097;Civ' C - .M, U "J:
ADDRESS /Z, �
Lender's Name S'+�
- r CITY ON Uig' Qom- TEL NO 7)
i�•' .,, I t. i,
Lender's Address STATE GT cam- LIC
•1 certify that I.have read tfiis•application and state that the above LICENSE NO �.a7S2�..a. CLASS
Information is correct I agree to comply with all County ordinances "-
,,ancf State laws relating'to budding construction,and hereby authorize
representatives of this County to enter upon the above-mentioned _
pro for Inspect n purposes SEE REVERSE^FOR EXPLANATORY LANGUAGE. ' ,9 `
r
t�
SIGNA RE OF APPLICANT R AGENT DATE•, ., _ " ,