HomeMy Public PortalAbout6114 GOLDEN WEST AVE_Mechanical__ WOR:ERS'COMPENSATION DECLARATION CEA 818 (2.80) O p pUC Qtr S O N FOR P E R M ff
I hereby affirm that I have S'certificate of consent to self
insure, or a certificate of Workers'Compensation Insurance,or H[ A711NG-V[ENTlLATING-AlR CONDOTI®NII`�G
a certified copy thereof(Sec.3800,Lab.C.)
Policy No. Company COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is hereby furnished.
El Certified copy is filed with the county building inspection — BUILDING -�
department. FOR APPLICANT TO (FILL IN 1
Date Applicant (PRINT OR TYPE ONLY) ADDRESS }lA___��Ve
�jJ y 1
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITYe l.� —1, '
COMPENSATION INSURANCE NEASSEST }
(This section need not be completed if the work involved ABSORPTION UNIT, BTU CROST. {"\ , tl
by the permit is for one hundred dollars ($ICO) or less.) DISTRICT NO. PROCESS, Y O
I certify that in the AIR HANDLING UNIT,CFMcc
y performance of the work for which this ) O
permit is issued, I shall not emplo,, any poison in any manner i
so as to--b�77ecomC/e� subject to the Y o/kerss' C�om/preensaV Laws. ; SOI LER, BTU—
APPROVALS
Date~` (���pplicant_/�T 'V(_�(/1 APPROVALS DATE I PECTOR'£=1GN TORE IU
COMPRESSOR,BTU d
ROUGH _�� _ _ to
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM
Exemption, you should become subject to the Workers' FINAL
Compensation provisions provisions of the Labor Code, you must forth-
with comply with such provisions or this permit shall be EVAPORATIVE COOLER VALID TION
deemed revoked. ' FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR: BTU
I hereby affirm that I am licensed under provisions of Chapter fI HEATER: SUSPENDED UNIT
9 (commencing with Section 7000) of Division 3 of the Busi- WALL
ness and Professions Code, and my license is in full force and i Q�.1 n /l
effect. Gtr\ ��C�_ _V
License Number Lia Class
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). iI PERMIT ISSUING FEE $
Lic.or Reg.No. Date �( TOTAL [FEE
HOME OWNER-BUILDER DECLARATtnnr I PLAN CHECK APPLICANT
I hereby affirm that I am exempt from, the Contractor's i NAME
License Law for the following reason (Section 7031.5, Busi- -—--— —
nes and Professions Code): ADDRESS
)_ � 1, 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). [�
!!OWNER ) V�s�/'1'
1, as owner of the property, am exclusively contracting I
with licensed contractors construct the project MAI
Professions
(Section 7044, Business and Professions Code)- i ADDRESS
TEL. NO.
CONSTRUCTION LENDING AGENCY CITY
I hereby affirm that there is a construction lending agency '
for the performance of the work for which this permit is ;ICONTRACTOR c/
^f } ^i 5}
issued (Sec. 3097,Civ.C.).
Lender's Name ADDRESS
Lender's Address CITY T 3 . NO.
I certify that I have read this application and state that the IISTATE LIC.
above information is correct.I agree to comply with all County _LICENSEO. CLASS
«iC
ordinances and State laws regulating Heating, Ventilating and Is,l
Air Conditioning, and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
County tr enter upon th Jbove•r antioned property for
inspe:',or qu- 6/i�, _ N CD 0 �r
Signat re of Permittee Date
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