HomeMy Public PortalAbout5757 GOLDEN WEST AVE_Mechanical__ ��- ;.,.WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
P hereb;% affirm that I have a certificate of consent to self
insurR, or a certificate of Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof (Sec. 3800, Lab. C.) 76A364C
CE-818(REV. 10/81)
Policy No. Company
Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
❑ Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING ��
tion department. (PRINT OR TYPE ONLY) ADDRESS
Date Applicant LOCALITY
7' C-
NO. TYPE OF APPLIANCE OR EQUIPMENT FEEi
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST.
ABSORPTION UNIT, BTU DISTRICT NO. PROCESSED BY
(This section need not be completed if the work involved by
; v-
the permit is for one hundred dollars ($100)or less.)
AIR HANDLING UNIT,CFM
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 become subject to the Workers'Compensation
Compenssatti,00n Laws. BOILER, BTU APPROVALS DATE INSPE 'S SIGNATURE
Dates Applicants�r "�'' COMPRESSOR, BTU U ROUGH
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER LID I N ;
with comply with such provisions or this permit shall be I
deemed revoked. FURNACE: FAUGRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU y �"�d . /
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 WALL
and Professions Code, and my license is in full force and effect.
LicenseNumb s7Z4 1 L Lic. Class�n , V
Contract�� 4yy��Date
❑ I am exempt under Sec. V
Plan check fee
B.&P.C. for this reason
PERMIT ISSUING FEE $
Date:
T
Signature OTAL FEE
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License ,
Law for the following reason (Section 7031.5, Business and NAME
Professions Code):
❑ I, as owner of the property, or my employees with ADDRESS # o;Yf 6 td
wages as their sole compensation,will do the work and
the structure is not intended or offered for sale(Section CITY TEL. NO. r,
7044, Business and Professions Code). 0 0 0j$T`j 0
OWNER G
❑ I, as owner of the property, am exclusively contracting .0 2 03-88
with licensed contractors to construct the project (Sec- MAIL
tion 7044, Business and Professions Code). ADDRESS
CONSTRUCTION LENDING AGENCY CITY TEL. NO.
I hereby affirm that there is a construction lending agency for ,
the performance of the work for which this permit is issued CONTRACTOR
(Sec. 3097, Civ. C.).
ADDRESS
Lender's Name ���G VIP
ELICENSE'
TEL. NOLender's Address LIC.
I certify that I have read this application and state that the O. _ , ,�i / CLASS 4::---
above
above 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
u on the bov1tioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date