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HomeMy Public PortalAbout5819 GOLDEN WEST AVE_Mechanical__ DECLARATI WORKER;SCOMPENSATate of consent to 76A346DPW9,69 APPLICATION FOR PERMIT LIME GREEN,, 76A364C I;'vereby affirm tlLat I have a certiSicate of consent to self insure, or a ceYtificate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING -AIR CONNING copy-thareof(Sec.3800 Lab C.) -- — - - - - - --� -- -- _ - - Policy M110.• 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 BUILDING department. (PRINT OR TYPE ONLY) ADDRESS Date Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY NEAREST jj ,( ' `�'�( CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST. [___�J ' TLY01d> COMPENSATION INSURANCE ABSORPTION UNIT,BTU This section need not be completed if the work involved b ASSESSOR ( P Y the MAP BOOK PAGE PARCEL permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO. PROCESSED BY I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to BOILER,BTU. D P become subject to the Workers'Compensation Laws. x 9000 ,�T� a COMPRESSOR,BTU APPROVALS DATE INSPECTOR'S SIGNATURE Date Applicant VENTILATION SYSTEM NOTICE TO APPLICANT: If,'.after making this Certificate of ROUGH Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER provisions of the Labor Code, you must forthwith comply with such FINAL 2. - provisions or this permit shall be deemed revoked. FURNACE: FAU GRA I LICENSED CONTRACTORS DECLARATION FLOOR BTu Bo t/p VALIDATION I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED—UNIT— (commencing USPENDED UNIT(commencing with Section 7000) of Division 3 of the Business and WALL Professions Code, and my license is in full force and effect. 4 ` J '/•D� 1,4 �. License Number Lic.Class H.+ 3 a Contractor Date _ O ❑ Plan check fee jU am exempt under Sec. cc zy B.&P.C.for this reason PERMIT ISSUING FEE$ Q a� O TI pis -� - !- Date: TOTAL FEE °` `U UlJ Signature I© �© ,;efY W PLAN CHECK APPLICANT _ OWNER-BUILDER DECLARATION a�i;:.�t� n z_".9 Z_ . .. _ _ I hereby affirm that I am exempt from the Contractor's License Law NAME for the following reason (Section 7031.5,.Business and Professions LAI WQ , ADDRESS a} ;_:- sr LJ�� 'j`E:.•`?: 1, as owner of the property, or my employees with wages - as their sole compensation, will do the work and the CITY - TEL.NO. t�.:_�_. � �;yc,_� structure is not intended or offered for sale (Section 7044, Business and Professions Code). OWNER I, as owner of the property, am exclusively contracting MAIL with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions..Code). CONSTRUCTION LENDING AGENCY CITY TEL.NO. I hereby affirm that there is a construction lending agency for CONTRACTOR , the.performance of the work for which this permit Is issued (Sec. 3097,Civ. C.). ADDRESS " Lender's Name CITY TEL.NO. Lender's Address STATE LIC. I certify that I have read this application and state that the above LICENSE NO. 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 NATURE OF 4PrLICANT OR AGENT DATE WORKER'S COMPENSATION DECLARATION 20-0046 DPW 9/89 APPLICATION FOR PERMIT 76A364C I hereby affirm that I have a certificate of consent to self insure, ME or.a certificate of Worker's Compensation Insurance, Gr a certified HEATING-VENTILATING-AIR CONDITIONING GREEN 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 ADDBUILDINGRESS department. (PRINT OR TYPE ONLY) LOCALITY Date Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST 00, CROSS ST. COMPENSATION INSURANCE ABSORPTION UNIT,BTU ASSESSOR (This section need not be completed if the work involved by the MAP BOOKPAGEp� PARCELa permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO. PROCESSED BY I certify that in the performance of the,work for which this permit is issued, I shall not employ any person in any manner so as to BOILER,BTU become subject to the Workers' Compensation Laws. /!O L COMPRESSOR,BTU '- APPROVALS DATE SPECTOR'S SIGNATURE Date Applicant VENTILATION SYSTEM NOTICE TO APPLICANT: If, after making this Certificate of ROUGHJ Exemption,you should,become subject to the Workers'Compensation EVAPORATIVE COOLER provisions of the Labor Code, you must forthwith comply with such FINAL provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY VALIDATION LICENSED CONTRACTORS DECLARATION FLOOR BTU 1 hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT o (cmmencing with Section 7000) of Division 3 of the Business and W LL Professions Code, and my license is in full force and effect. /Y e9z License Number.. ' /}*4U Lic.Class Contractor t Date 0 ❑ I am exempt under Sec. Plan Check fee V Q B.&P.C.for this reason PERMIT ISSUING FEE$ O Date: TOTAL FEE W Signature 11. OWNER-BUILDERDECLARATION PLAN CHECK APPLICANT en I hereby affirm that I am exempt from the Contractor's License Law NAME poll.for the following reason (Section 7031.5, Business and Professions Code): ADDRESS I, as owner of the property, or my employees with.wages t= El as their sole compensation, will do the work and the CITY TEL.NO. 303 0.V, structure is not intended or offered for sale (Section 7044, y F-1e Business and Professions Code). WNER xii, t i F —h �-4 1, as owner-of the property, am exclusively contracting MAIL TS_I7tHL 3 -90 with licensed• contractors to construct the project (Sec- ADDRESS �� �su I _V Jo=O`r' tion 7044,Business and Professions Code). (,aIL4:I% CITY TEL.NO. CONSTRUCTION LENDING.AGENCY � ( �f7 G t-� •r��Y '�l I hereby affirm that there is a construction lending agency for ' CHANGE _� the performance of the work for which this permit Is issued ONTRACTO — �� (Sec.3097,Civ. C.). ADDRESS . E1000--000{ 5/30/95 Lender's Name 7-km ejc�? [STATES!ENQ Y Rulka aTE NO.iS I� �/ Tj }j — Lj Lender's Address LIC. I certify that I have read this application and state that the above ENCLASS 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 in spection pur oses. SEE REVERSE FOR EXPLANATORY LANGUAGE SIGNATURE OF APPU[ifOR AGENT DATE -