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HomeMy Public PortalAbout5938, 5938 1/2, 5940, 5940 1/2 GOLDEN WEST AVE_Mechanical__ WORKERS' CUMA('ATION DECLARATION f I hereby affirm That I hdve-a certlflcafe a�ra�iser4 to self ' f APPLICATION FOR PERMIT Insure, o,a certi%4'me of_Worker3 Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING or a certified copy thereof (Sec 3800, Lab C ) 76A364C 20-0046 DPW 9/88 Policy No Company ❑ Certified copy Is hereby furnished COUNTY OF LOS ANGELES BUILDING.AND SAFETY T-1- Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING - 2Q hon'department ADDRESS j�//((�j t 11 ,, I - (PRINT OR TYPE ONLY) Date Applicant• LOCALITY NO TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE'OF•EXEMPTION FROWWORKERS' NEAREST COMPENSATION INSURANCE CROSS ST ' e• ABSORPTION UNIT, BTU' (This section need not be completed if the WOrI(involved by DISTRICT NO PRJY ED BY the permit is Fdr'one hundred dollars ($100)'or'less.) �,// (''certify That in the peiformancb of the work for which this AIR HANDLING UNIT, CFM jo Permit`•is�issued, I`shall not employ any person'in any manner so as to become subject fa the Workers'Compensation Laws BOILER, BTU APPROVALS DATE INSPE OR'S SIGNATURE Y i °` h COMPRESSOR, BTU ROUGH n ra r Date Applicant I l c NOTICE TO APPLICANT tf,+after«making this Certificate of FINAL VENTILATION SYSTEM V 'Exemption;. you,,should become-subject to the Workers' �- " Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER ,VA.L DATION' with comply with such'.provisions or this permit shall be deem- ed revoked F * ` - FURNACE FAU GRAVITY ! � • LICENSED CONTRACTORS DECLARATION - FLOOR BTU I hereby affirm that I am licensed under,provisions of Chapter 9 HEATER ' SUSPENDED ° UNIT— 60 (commencing with Section 7000)of Division 3-of the Business WALL ]C and Professions Code„and my license is in full force and effect License Number } LIc'Class , 00 '_Contractor Date oC ❑ ?-ham exemjit under Sec• O _ Plan check fee u B.BP C for this reason O H t. Date PERMIT ISSUING FEE $ Z TOTAL FEE ' — Signature .OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT 1•hereby affirm that I am exempt from the.Contractor's License Law for the following reason (Section 7031 5, Business and NAME- Professions Code) O J ` ❑' I, as.owner of the pADDRESSroperly, or •rimy employees with �„ wages as their sole compensation, will do the work and ACC'T.a the structure is not intended or offered for•sale(Section CITY TEL NO, , 7044, Business and Professions Code) 3307 .:rJ.Oft OWNER I, as owner of the property;am exclusively contracting T f EC with licensed contractors to construct the project (Sec- MAIL tion 7044, Business and Professions Code) ADDRESS TOTAL 25 00 .CONSTRUCTION LENDING AGENCY � 1 ._ ® moi CITY ' TEL NO !/fl I hereby affirm that there is a construction lending agency for CHECK 15,130 the performance of the work for which this permit is issued CONTRACTOR (sec 3097, Cio c ) _ oil” ' CHANGE .011. ADDRESS Lender's Name p Lender's Address i ' CITY TEL NO 13OOO-1]001 1/1- 5/90p� LIC I certify that I have read this application and state that the STATE NO• _ CLASS 8254 1 AI I1'.'6 above Information is correct'I agree to comply with all County ordinances and State laws relating to building construction, and herebykathorize representatives of this County to enter upon the anto ned p operTy for In pectin 4urposes I ` O SEE REVERSE FOR EXPLANATORY LANGUAGE J _ Signature of A nt Date ©s