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HomeMy Public PortalAbout5930 GOLDEN WEST AVE_Mechanical__ WORKER'S COMPENSATION DECLARATION 20-0046 DPW 9/89 APPLICATION FOR PERMITLIME GREEN c� e - 76A364C I hereb9 rm that L Mavb a'certificate of consent to self insure, or a certificate of Worker's Compensation Insurance, or a certified HEATING -VENTILATING -AIR CONDITIONING 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. EJCertified copy is filed with the county building inspection FOR APPLICANT TO FILL IN nUDRi="S3 r (k/ department. (PRINT OR TYPE ONLY) Date Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST CROSS �`i C [ 4- J_ ABSORPTION UNIT,BTU ASSESSOR J A COMPENSATION INSURANCE f (This section need not be completed if the work involved by 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 ,Q become subject to the Workers' C ensatio aws. COMPRESSOR,BTU BO Q APPROVALS DATE ;INSPECTOR'S SIGNATURE - Date — Applican VENTILATION SYSTEM NOTICE TO APPLICANT: If, ft making this Certificate of ROUGH Exemption,you should becom 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 LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATION 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 and WALL Professions Code,and my license is in full force and effect. Z. r f) �/ f1 t Z �9 l� ) iJi�lY C00 License Num er •� ✓ 1 4 Lic.Class © Q' YlO (1 > (/ Contractor Date IF— t1_2 / V-fbs'+y _371 ®® , F1I am exempt under Sec. Plan Check f2@ V B.&P.C.for this reason PERMIT ISSUING FEE $ , 0 Date: TOTAL FEE Q� W Signature o- OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT " CO I hereby affirm'that I am exempt from the Contractor's License Law NAME C for the following reason (Section 7031.5, Business and Professions `� l Code): ADDRESS V L / .=•_'`I;1 11.7n0I ElI,'as owner of the property, or my employees with wages as their sole compensation, will do the work and theCITY TEL.NO. ` -` ' structure is not intended or offered for sale (Section 7044, C �,JJ C "+•r^3" ' a Business and'Professions Code). OWNER AL JD �U L ❑ I, as owner of the property, am exclusively contracting HE '; 3� i MAIL _p}- with licensed contractors to construct the project (Sec- ADDRESS �s J S� f tion 7044;Business and Professions Code). U.:,.:~� CONSTRUCTION LENDING AGENCY CITY I GY TEL.NO. I hereby affirm that there is a construction lending agency for CONTRACTOR 117��� the performance of the work for which this permit Is issued (Sec. 3097,Civ. C.). 1. t 'r/' Z(D�GG , ;`D 0 Lender's Name ADDRESS �) 0(D /I� p _ z I•f "+ CITY /J r,L` T 18,kEL.NO. �,�. fd (j - Lender's Address STATE LIC, S I certify that I have read this application and state that the above LICENSE NO. r ( CLASS information is correct. 1 agree to comply with all County ordinances nd State laws relating to building construction,and hereby authorize r presentaat of this County to enter upon the.above-mentioned 6roperty�2 f inspecti p rposes. SEE REVERSE FOR EXPLANATORY LANGUAGE IOGNATUWOP AP71&thNT10R AGEINT ' 'N DATE