HomeMy Public PortalAbout6059 GOLDEN WEST AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION 76A364C o no p p o� no 0
I hereby affirm that I have a• certificate of consent to self cE-818 (2.80) Q P II L��C Q T Q O'U V FOR If� E R IIUI}ff
insure,or a certificate of Workers'Compensation.insurance,dr H,LisA711 NG-V fE;NTI L/1TONG_AIR CONI DOTOO 11MG
a certified copy thereof(Sec. 3800,Lab.C.)
Policy rtified copy is hereby furnished.Compan
Certified
COUNTY,OF LOS ANGELES SUOLDING AN D SAFETY
Certified copy is filed with the county building inspection FOR P6�L9CNT fO FILL IN BUILDING ` C
department.
Date Applicant (PRINT OR TYPE ONLY) ADDRESS
LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE _
COMPENSATION INSURANCE NEAREST ` ' r
(This section need not be completed if the work involved ABSORPTION UNIT, BTU CROSS ST. " Z� - r 0
by the permit is for one hundred dollars ($100) or less.) DISTRICT NO. PROcessEY _ 0
1 certify that in the performance of the work for which this AIR HANDLING UNIT,CFM ,/
permit is issued, I shall not employ any person in any manner u 0
o as to become subject to the W ro Je cation Laws. BOILER, BTU
r APPROVALS DATE INSPECTOR'S SIGNATURE W
Date Applicant CFS-- COMPRESSOR, BTU 6 N
ROUGH
TICS TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM ,� z
Exemption, you should become subject to the Workers' FINAL _ l
Compensation provisions of the Labor Code, you must forth- VAPORATIVE COOLER VALIDATION
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR, BTU b2lf'
I hereby affirm that I am licensed under provisions of Chapter HEATER: ENDED. UNkT
(commencing with Section 7000)of Division 3'of the Busi- WALL 6
ness and Professions Code, and my license is in full f rce and
effect.
License Numberr /zj/ /1"Lic.Class
Zal
Contractor Date
I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer Plan check fee 25%of above.
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code). EERMOT ISSUING FEE$
Lic.or Reg.No. Date TOTAL (FEE 1,
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from-the Contractor's NAME
License Law for the following reason.(Section 7031.5, Busi-
ness and Professions Code): ADDRESS
I, as owner of the property, will do the work and the CITY TEL.NO.
structure is not intended or offered for sale (Section
7044, Business and Professions Code). 2,17 3,8 A- "
OWNER
I, as owner of the property, am exclusively contracting vi #f•y o o m.a 8 -
with
.with licensed contractors to construct the project "MAIL
(Section 7044, Business and Professions Code). ADDRESS (, f
2 ®x® 27,00 . .
T TEL.NO.� �/
CONSTRUCTION LENDING AGENCY CITY• I �/ � Y o,o 00 217,0 '
I hereby affirm that there is a construction lending agency 4ou
for the performance of the work for which this permit is CONTRACTOR C
issued(Sec. 3097,Civ.C.). _ — 4- - 1-0,28-81
Lender's Name ADDRESS
Lender's Address / NO.
CITY - _ -
I certify that I have read this application and state that the STATECLASS
above information is correct.I agree to comply with all County LICENSE NO. `3
ordinances and State laws regulating Heating, Ventilating and
Air Conditioning,and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
County to enter upon the above-mentioned property for
/f f . poses.
I C<Ll�
Signature of Permittee Date