HomeMy Public PortalAbout6032 GOLDEN WEST AVE_Mechanical__ ION
DECLARATI
WORKER'S h ve a certificate
of consent to 76A346DPW9/89 APPLICATION FOR PERMIT LIME GREEN
76A364C
I hereby of€if'm that I have a certificate of consent to self insure,
o; 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..
❑ Certified copy Is filed with the county g buildin inspection FOR APPLICANT TO FILL IN BUILDING
department. (PRINT OR TYPE ONLY) ADDRESS
Date Applicant LOCALITY �G
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST'
CROSS ST.
COMPENSATION INSURANCE ABSORPTION UNIT,BTU
(This section need not be completed if the work involved by the ASSESSOR .
MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less.)
AIR HANDLING UNIT,CFM DISTRICT NO. PROCESSED BY
I*certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU
become subject to the Workers' Compensation Laws.
COMPRESSOR,BTU g6e
Dat: -�� Adtc_]./a APPROVALS DATE INSPECTOR'S SIGNATURE
pplicarVENTILATION SYSTEM
-NOTICE TO APPLICANT: If, after making this Certificate of ROUGH el- f_
Exemption, you should become subject to the Workers'Compensation EVAPORATIVE COOLER _
provisions of the Labor Code, you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAV VISY
LICENSED CONTRACTORS DECLARATION / FLOOR BTU' �C P VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT
(commencing with Section 7000) of Division 3 of the Business and HEATER: WALL
Professions Code,and my license is in-full force and effect.
License Number 12 Lic.Class �2—
e5_.-_?0 �5l e 0 , O
Contract -� Date �
❑ I am exempt under Sea Plan Check fee
B.&P.C.for this reason PERMIT ISSUING FEE$ �p U
Date: TOTAL FEE d
Signature V)
PLAN CHECK APPLICANT
OWNER-BUILDER DECLARATION 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 ,.
Code): ADDRESS
❑ 1, as owner of the property, or my employees with wages
as their sole compensation, will do the work and the CITY TEL.NO.
structure is not intended or offered for sale (Section 7044,
Business and Professions Code). OWNER TT7' y
❑ i �'
I, as owner of the property, am exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRESS I_I~i l ILIS 1 d 09
tion 7044, Business and Professions Code). E_,-• F i
CONSTRUCTION LENDING AGENCY CITY TEL.NO. :.fit :_,:.
I hereby affirm that there is a construction lending agency for 3•('- ,i;jj
the performance of the work for which this permit Is issued CONTRACTORf —
(Sec.3097,Civ. C.). A n
ADDRESS /��//.
Lender's Name CID,j_I— I:jhj T s
� ssDfy ` k
CITY TEL.NO.
l.
Lender's Address STATE LIC. 5IRf-'
,3p?Gj �I 'f j'
I certify that I have read this application and stale that the above LICENSE NO. CLASS C L 0
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
3-7- 91
SIGNATDR6 OF APPLICANT OR AGENT DATE -