HomeMy Public PortalAbout5838 GOLDEN WEST AVE_Mechanical__ j d WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
e rm that 1-have,a certificate of consent to self
it re, car 8 gertificate ®f Alorkeis' Compensation Insurance, HEATING VENTILATING - AIR CONDITIONING
,or a„c,rtified copy thereof (Sec. 3800, Lab. C.) CEA3818'(REV. 10/81)
Policy No Company
Certified copy is hereby'furhi'shel 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 4
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
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 !/
the permit is for one hundred dollars(;100)or less.)
AIR HANDLING UNIT, CFM' v V
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 Laws. BOILER, BTU APPROVALS DATE INSPECIVIS SIGNATURE
f6100 -ZO
�j /` d COMPRESSOR, BTU_3d ROUGH 4�' 01A-•—
.Date / � Applicant �� �J
NOTICE O APPLICANT: If, after making This Certificate of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers' {CJi V
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VAL_t) A'i�N
with comply with such provisions or this permit shall b
deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU (V UV
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.
O
License Number Lic. Class ,
Contractor Date
❑ 1 am exempt under Sec.
Plan check fee A.
B.BP.C. for this reason PERMIT ISSUING FEE $ S z 0 7 LL 7 A
Date:
TOTAL FEE SI)
Signature � ° 030.50
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 ► ° ° ° 3 Q 5 0
Professions Code):
1, as owner of 'the property, or my.employees with ADDRESS Q 9' 3'�8 8
El
wages as their sole compensation,will do the work and
the structure is not intended or offered for sale(Section CITY, TEL. NO.
7044, Business and Professions Code). meq'
OWNER
A/it— V / Z& £ .
I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec- MAIL
.tion 7044, Business and Professions Code). ADDRESS
CONSTRUCTION LENDING AGENCY CITY3 TEL. NO. ?Si�
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
CITY TEL. NO.
Lender's Address
STATE LIC.
I certify that I have read this application and state that the LICENSE NO. CLASS
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
up above-mentioned property for 0, pection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
-
Signature of Applicant or Agent Date