HomeMy Public PortalAbout6037-6039 GOLDEN WEST AVE_Mechanical__ WORKERS COMPENSATION DECLARA�fON 76A3640 - - pp p� -5� pp
1,hereby affirm that I have B,'certificate of consent t0 self CE-818 (2-80) A Imo,��� Y�� p�J "'o PERM17
insure, ora certificate of,Workers'Compensation Insurance,of E-4��+'I ING_UERlYIL�iTiIVG_�16a
CONDI IOFbIWCv'' `
a certified copy thereof(Sec 3800,Lab.C.)
°Policy No. 6ompany
':�Q�Cecrifiedroopy�is hereby furnishEd.� 4d° , �COUNTY�OF�LOS'AIVGELES�' �' � aBU1LDING AND SAFETY_ — -'
,Certified copy is filed wi'h the county building tnspection _ g'UI DING
department, FFOR`APPLICANT,TO°FILL IN- ADDRESS-(QO�j�
' Date Applicant w IPRINTOR�TYPE,ONLY,) '
a�
_ _ "" LOCALITY"1' pi , C
£RTIFICATEOF•EXEMPTIONFROMWORKERS' NO-`- �TYPE_OF,APPLIANCE OR-EQUIPMENT' �.�FE�E -
COMPENSATION INSURANCE. r _ NEAREST
(This secfion need'n t be cornple R osS sT >'
♦�, t) ted 1F the(�WOik involved_ ABSORPTION UNIT, BTU
by the pEtttilt is for 0710 I11111dICd dollars (y10�) OY less:) DISTRICTNO _ PROCESSED r
I certify that in theperfor'mairce of the work,for iv4kch this AIR HAN,DLINC3,UNIT,�C'FM
permit is issued, I shall not employ any,person.in any,manner-
so as V)become subject to the Workers' Compensation Laws 1301L'ER,'.BTU + q0
``F• -�APPROVAi Sz -
DATE'-- INSPECTOR'S SIGNATURE
` Date Applicant COMPRESSOR;BTU lL
-ROUGH_ �� ✓ d.
- .NOTICE�TO APPLICANT:.If, after making this Certificat of., VEN7fLATiON'SYSTEM. _ - s �`
Exemption, you sfiould`become subject fo° the Workers', FINAL, 4.l e-r Z
_�
' Compensation provisions of the Labor Code, you must forth-;
EVAPORATIVE COOLER ' e� VALID`ATION
with comply with such provisions or this permit shall"be ;
deemed`revoked. FURNACE FAU GRAVITY
' LICENSED CONTRACTORS DECLARATION - FLOOR`- BTU
c I hereby affirm that I amlicepsed under provisions'of Chapter H; ATER a'SUSPENDED UNIT
9 (commencing with Section 7000)W Division'3 of the BusI- j - WAIL °" Z�p?JO 1(4--A,
x °
ness and Professions Code,-and my license is in full force and
effect.,.
License Number 4®- - ✓ nLic.Class/
Contractor_Nt Date
I am exempt from the licensing requirements as'I am a, -
licensed architect pr a registered 'professionalengineer Pjall check fee 25%'of abjoVe
acting in my professional capacity (Section 7051, Bus- a _ f
messPERMIT ISSUING FEE $
and Professions Code').
Lie.or Reg• No.- Date TOTAL FEE
HOME OWNER-$U,ILDE_ DECLARATION PLAN CHECK APPLIpCAN ,-
I hereby'a�firm that I .am exempt from=the'Contractor's NAME' �.
License Law for the following reason, (Section 703I 5, Susi- y
ness'and-Professions Code) t. ADDRESS y
1,-as owner of'the'property, will'do'the woik and the, fEL._NO.i�x �r €
structure is not intended •pr offered -for sale (Section CITY' c yr r
7044,Business and Prof'essioins Code)- _w ' - 12,V-A
r OWNER
1, as ownerof th'e' property, am.exclusively, contracting r #:otiet'e�q,(Ji�
With- licensed`,contractors� to construct the pioject MAIL '*�
-(Section 7044, Business and Profesiioes Code): ADDRESS �' 2 yip
CONSTRUCTION LENDING AGENCY- CITY , a TEL". NO' i
her'b affirm,thatthere,As a construction lendinga enc �,' ` > " >q p ,2i7"0
for theperof thetiwotk;for which this ermit s CONTRACTOR' �' `=°
issued(Sea.3097,Civ.C.). ;��7, '� 6.0-�8,0-
Lender's Name ADDRESS',
Lender's Address �1TY „ '' STEL:NO' fi
I certtfy`�that I have read 'his-application and.state'that'the _ STATE - - LIC i°
above infort"nation is correct:I•agree to comply with all County` LICENSE'NO . CLASS
ordinances and State laws regulating,.Heating, Ventilating and
Air Conditioninand hereby authorize representatives'of,this
g, SEE REVERSE FOR EXPLANATORYT ANGUAGE"-
County to entgr upon the above-mentioned property for, }
sprC, tton pi rposes. p x -
Signature Of Per�,ttee Date
71 A364C
CE-818(REV 6/78)
os"T. PPL TION FOR P IT = `
HEACTING -.VE TILATINGA( CONDITIONING ,' 3
COUNTY OF LOS ANGELES BUILDING.AND SAFETY
FOR APPLICANT TO,F,ILLIN4 BUILDING
ADDRESS
(PRINT OR TYPE ONLY) r � D 1 6[^E'L- } .-�/+r��7
_
LOCALITY
NO TYPE OF APPLIANCE OR EQUIPMENT FEE
NEAREST t
CROSS ST '
ABSORPTION UNIT,BTU +• {"�' /j�J -
OWNER
i
AIR HANDLING UNIT,CFM MAIL
_ + ADDRESS
r BOILER,BTU CITY TEL NO
J COMPRESSOR,BT,U' �+
CONTRACTOR�65 jleXT
•VENTILATION SYSTEM r - ADDRESS � f4
EVAPORATIVE COOLER' ` CITY I./1 TEL N0337 ^�� '
FLOORCE 'FAU BTU G A TY !T 7 S TATE LIC-
CENSE NO ;J ,,CLASS J6 '
HEATER _ SUSPENDED UNIT= _ _ l/�� APPROVALS ' DATEINSPECTOR S SIGNATURE- ,
WALL
ROUGH 13 •-
FIN AL. marl a
INSPECTION RECOR LJ
09
Plan check fee 25% of above
PERMIT ISSUING,FEE�'' Q Z
-TOTAL FEE
PLAN CHECK APPLICANT PLAN CHECK VALIDATION
NAME
'ADDRESS•
CITY '~ _ TEL NO { _ 8`4
p
ILION
HEREBY ACKNOWLEDGE THAT I HAVE READ THISAPPLICATION AND �• z•8`4 O,2 ASTATE THAT +
ALL
ORDINANCES ANDHE BTH ALL
OLAWS RVE IS EGULATINGRRECT HEATING,HEATING AGREE O VENTIILAT NCOMPLY IG}'AIR • • .•# Q 0,0 m 4 1
ING - - PERMIT.VALIDATION '' '
],HEREBY CERTIFY THAT I AM NOT ACTING-IN VIOLATION OF `-, - o 1 O ,,-00 .
9", DIVISION 3, OFTHE BUSINESS AND PROFESSIONAL CODE
STAT
HAT
TE OF CA IFORRNIA ' q !7 T /l�Ll' I � I Or11,OtOTEY���((( 011,04 '80 '
DISTRICT NO ,//�+ PROC SSED Y