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HomeMy Public PortalAbout5842 GOLDEN WEST AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR .PERMIT PERMIT I hereby affrrm that I have a certificate of consent to self - , Insure, or a certificate of Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING or a certified copy thereof (Sec 3800, Lab C ) 76W�4C CE=818(REV 10/81) Policy No Company Certified copy is hereby furnished COUNTY-OF LOS ANGELES BUILDING AND SAFETY ❑ Certified copy is filed wlfh the county building inspec- FOR APPLICANT TO FILL IN (�/]' tion department � _ \ (PRINT OR TYPE ONLY) ADDRESS Date Applicant LOCALITY NO TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST COMPENSATION INSURANCE I - CROSS ST BTU (This section need not be completed if the work Involved by. ABSORPTION UNIT, DlsraicT NO PROCESSED BY 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 J p 0- permit is Issued, I shall not employ any person In any manner so as to become subject to the Workers'Compensation Laws l BOILER, BTU APPROVALS DATE INSPECTOR'S SIGNATURE Dai "yZ pphca t / COMPRESSOR, BTU ' y_— ROUGH NOTICE TO APPLICANT If, after ma ting tis Certificate of VENTILATION SYSTEM FINAL Exemption, you should become subject to the Workers' _ Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER ' VALIDATION with comply with such provisions or this permit shall be / y { deemed revoked FURNACE FAU TY LICENSED CONTRACTORS DECLARATION FLOOR -BTU 10 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 d �{ ! O License Number -2326/Z LLic Class 2-0 - U ac or Date �Z�D ; ❑ I am exempt under Sec ; Plan check fee IL H B&P C for this reason Date PERMIT ISSUING FEES a %`fl rZ TOTAL FEE 3 o la A Signature ;� aoaag OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT I hereby affirm that I am exempt from the Contractor's License /,'-,- ,3 0,5 0 Law for the following reason (Section 7031 5, Business and NAME Professions Code) a o 0 3 Q J� 5• 1 ❑ 1, as owner of the property, or my employees with ADDRESS wages as their sole compensation, will do the work and the strbcture Is not intended or offered for sale(Section CITY TEL NO 7044, Business and Professions Code) I o ' [MAIL WNER ❑ I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec- - tion 7044, Business'and Professions Code) ADDRESS CONSTRUCTION LENDING AGENCYCITY TEL NO L 1 hereby affirm that there Is a construction lending agency for the performance of the work for which this permit is Issued CONTRACTOR C , (Sec 3097, Civ C ) - = ADDRESS ed - Lender's Name CITY TEL d Lf 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 jaws relating to building construction, and hereby authorize representatives of this County to enter upon abo -me ne property for inspection purposes SEE REVERSE FOR EXPLANATORY.LANGUAGE Signature of Applicant or Agent - Date -• - - - rl