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HomeMy Public PortalAbout5704 GOLDEN WEST AVE_Mechanical__ WORKERS'COMPENSATION,DECLARI:TION 76A364C` APPLICATION � �j p p `� i,h hereb�. :ffiim that •I hai,eENS a •certificate of consent to self CE-&18 (2-80)' _�P If� LL IC AT I O �I FOR P E R M � !� I or i;ertificate'of Workers'Compensation Insurance,or HEATING-VENTILATING-Al-R'CONDITIONING a certifies copy thereof(Sec. 3800,Lab C) Fgd Policy No. Company COUNTY'OFryLOS ANGELES BUILDING.ANb SAFELY Certified copy is hereby furnished. 'Certified copy is filed with,the co my bu dingi ection 'FOR APPLICANT TO FILL IN ' euILDIruG y�/�•' Qtly ��- )epar enyi 1 e L� Date Applicant 'IPWNT OR TYPE7ANI1Y) ADDRESS LOCALITY CERTIFICATEOFEXEMPTION FROM WORKERS' NO: TYPE OF APPL�I'ANCE,OWEOUIPMENT, F,EE t4 COMPENSATION INSURANCE > � NEAREST' Yg �. CROSS ST. /� •p (This section' need-not be completed ift_the work-involved ABSORPTION.UNIT, BTU '� _, `p by the peimit is for orie hundred dollars ($100) ols .) DISTRICT NOPRosseD U 1 .' >; certify that_in the performance of the work'for WhichAIRHANDLING UNIT,this � _ permit is issued, I shall not employ any person in any Manner '-� t, ; i _ "�L � O so as-to become subject to the Wo'rkers'-Compensation Laws BOILER, BTU v - r APPROVALS DATE INSPEC'TO SIGNATURE U' 11J Date >' pplicant COMPRESSOR, BTU ROUGH b�7j _ � NOTICE TO APPLICANT:,If, after making this Certiftcaie'of" VENTfL`ATION SYSTEM Z " Ezem tion, subject, „ FINAL _ p you, should become to the Workers' ' CompAsatrori provisions, of the Labor Code, you must forth- r VALIDATION EV APOFIATIVE-COOLER, . with comply`with such' provision`s=,or-ihis`per'mit,shall'be`'� ' deemed revoked s I-- FURNACE. FAU- GRAVITY- ;, >R LICENSED CONTRAGTORS DECLARATION FLOOR 67U - I hereb,q affirm that I am licensed under provisions of,Chapier _ HEATER. SUSPENDED UNIT,.. 9 (commencing with Section.7000)of Division'3 of the Busi- ”` _ WALL - ness and Professions Code, and my license Win full force and effect. 7� (� �. :GP/y'C/ (,'� � 9"Q'4�A Licen"se Numbe •I:ic. Class �, ' #_'0,0'8. 0 08 Contractor - _ ET I am exempt from-the licensing requirements a,S J"'m a licensed architect or, a registered professional engineer , Plan cheek fee 25%of above. acting in my professional' capacity (Section 7051, Bus- > mess and Professions Code). PERMIT-ISSUING FEE $ `j(,1 Icor Reg No. Date •TOTAL FEE ' HOME OWNER-BUILDER DECLARATION PLAN-CHECK APPLICANT ` I hereby affirm that "I am exempt from ttie Contracfor;s- ,NA6i?8-a U License Law for the'following reason (Sectiow 7031 5; Busi Hess and Professions Code) ADDRESS d �TjliC/� p�d �Q C.ICY _I;.as owner of the pioperty, will do the work and the ` 'J, CITY ` TEL. N9 _ structure,is ,not intended or offered for sale (Section. / �'7 ��,'.����, 7044,,Business and Professions.Code).> a ' ,".; t, s OWNER !'Z s I, as mwner�of the property, am exclusively contracting !_ _ _ ,-with licensed •contractors to construct„ the project" MAIL (Section 7044, Business and ProfessiUr"s•Code) ADDRESS. _ CITY .�--y� � � TEL. NO��� �V , CONSTRUCTION LENDING AGENCY , _ /' :, -r y I hereby affirm that .there'is a construction lending agency for the performance of,ihe work for-Which this-permit Is CONTRACTOR issued the. 3097,Civ.C) -- Lender shame ADDeR�ES l q `71/ Lender's Address [SL ITY� �` C� TEL. !NO'.'.I certify•that I have read this application and state thai'the TATE l z LIC:above information is correct.I agree to comply with all County ICENSE NO.��! 2 CLASS ordinances and State laws regulating Heating,-Ventilating and " Air Conditioning, and hereby authorize representatives of this SEE REVERSE,FOR EXPLANATORY LANGUAGE.,.,- - County to enter upon the above-mentioned property for mspec o purpose ��� Signat a of Permittee itKc1.5'COIMPENSATION DECLARATION 7CE 6A8 8(2-80) - A !!— I� � CAT0O �1 F®RPERM M I hereb`• affirm that I Ifaye v certificate of consent to self insure o� a cer,ificate of Workers'Compensation Insurance,or - HEATING-VENTILATING-AIR CONDIYIOP�ING a certtfie�G copy tth/ereof(Seb..'9Sob,r ab.'C.) Policy k/.7 i��/�/npany eI" { Ce:ti£iod copy is hereby furnished �� .-� �'?/ GOIJ�lTY OF LOS AfiIGELE BUILDING AND,SAFETY Cert iron ion ,�tiled with the co Int blildirig3n lection BUILDING tV� / �� s �µr �Me,_ FOR APPLICANT TO FILL IN IIa � J _ (PRINT OR TYPE ONLY) ADDRESS ^ ✓— LOCALITY , CERTIFICATE 6t,EXEMPTION FROM WOR-CERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE • COMPENSATION INSURANCE NEAREST; CROSS ST (a4_ Ipt�5n-need not be Completed if the work involved ABSO.RPTION UNIT, BTU f)y` the U 1Tn C 1&„fot' one-hundred dollars (&100) or les$.) DISTRICT NO PROCE c Y I certify that in the patformance af.the work.tor Which this AIR HANDLING UNIT,CFM permit is nsu.ad, I shall not employ any person in any manner, go`as.to'iaecome subject to the Workers' Vompensation LawsBOILER, BTU e ° �� - APPROVALS _ DAl E. INSPtCTOR'SSI6N aE• "0 ate', Applicant COMPRESSOR,BTU' 60'-ROUGH "W• NGTTCF TO APPLICANT: If, after making this Certificate of VENTILATION•SYSTEIVI Exemption, yuu sfi�uid become subject`to the Workers'- - - _FINAL Z• Curnpenaation provisions of ttfe Labor Code, you must forih- EVAPORATIVE•COOLER• V L ATION Athr cwiiplp-�k Itis such provisions or this permit shall'be - — '. d'ee•7latt re:yoked - V� / FURNACE, FAU GRAVITY, LICZNSED CONTRA&ORS DECLARATION FLOOR' BTU— _ _ ' 1 hereby Pffirm that I ani licensed iindeg provisions of Chapter HEATER. SUSPENDED KNIT ' e, (rumriencing with Section 7000)-.of Division 3 of the'Busi- WALLLid mess and Professions Code;ah[-my license is in full force and effort. l.icewxP ai• �Lac.Class E`710 ,. _ - • , , - n . Date 1-am ex6mpt'ijom the licensing-regyireinents as I am a - Lcer•sed archltec, or-a registered•professional engineer Plan Check fee 2r%of above. c seting in my p.ofessioltal' capacity (Secyion 7,0$10 Bus- iness and P.ra£essiorts'Code), PERMIT ISSUING FEE $ Lic or Rea_ivo_, Date ;TOTAL FEE H01viE OWN ED-$UILDER,DECLARATION PLAN CHECK APPLICANT, U ' I hereby affirm that 1,-am exempt from-the Contractor's NAME Licenst Lav` for the.following reason (Section 7031.5, Busi- ness and Professions Code), iADDFIESS - 1, as�'o"er'of-the property",-viii1l'do the work and the - CITY - TEL. NO. �S1 ,$-2-0 A, structure ir,.not intended or offered for sale (Section . F 704 ,.Businessand-Professions Code) #lob o',o' o o fj' �f ?,-as.-as.owner o£the property, am excltt•sively-contractOWNER,ing �o mvritl+ licen50d, ug[tittactors•to constiuct the project MAIL � era 3'7 (Seco"7044,_nusmess and Professions Code). ADDRESS 33,GO U CONSTRUCTION LENDING AGEN01 CITY' � TEL.NO,2��—��© r' I hereby affirm that thefe is a construction lending agency8r�{= for -tlie performance of the work fpr whtbh this permit is CONTRACTOR �� issued 'Sec,3097,Civ.C.). ���� �''• '•'� Lender's Name, 'ADDRESS lsa� Lender'sAddress CITY �i'! Ty NO��/c+ S �r _ I certify that i ;rave rr;ad this,application and state'that the gTATE LIC• above lnformatinti is correct I agree to comply with all County LICENSE NO � CLASS mdinanteS and State taws-regulating Heating, Ventilating and tUr Cenci;+;naing,and hereby authorize representatives of this SEE REVERSE FORJ;XPLANATORY LANGUAGE Ca . r' •to otter upon the,above-mentioned property for mspeCiipie• �";' I" `.P�r� ,ee Date