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HomeMy Public PortalAbout6120 GOLDEN WEST AVE_Mechanical__ TION WORKERS' CI have c6rti DECLARATION if APPLICATION FOR PERMIT I .here`'oy affirrh that I have a c@rtificate of consent to self • • it sure, or a certificate of Workers' Compensa4ion Insurance; HEATING - VENTILATING - AIR CONDITIONING oria certif�iddd copy the'rreoi��(Sec. 00, Lab. C�)//j�QJ ?76A364C Y i,. '_�'c� +y6'J- 46 DPW 9/88 Polic No. Company ❑ Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING / e/ Ay j� c+7- tio de or men ADDRESS ® ��/< (JVu� J (PRINT OR TYPE ONLY) cc I ��J�` Date Applicant LOCALITY C / y NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTI N.FROM WORKERS NEAREST COMPENSATION INSURANCE CROSS ST. (This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO. PROCESSWY the permit is for one hundred dollars ($100) or.less.) I 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 (t so as to become subject to the Workers' Compensation Laws. BOILER, BTU APPROVALS DATE SPECTOR'S SIGNATURE Date. Applicant COMPRESSOR, BTU ROUGH NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION with comply with such provisions or this permit shall be deem- ed revoked. FURNACE: FAU VIT LICENSED CONTRACTORS DECLARATION FLOOR BTU I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT-(commencing with Section 7000)of Division 3 of the Business WALL and Professions Code,and my license is in full force and effect. License Number Lic. Class " ' I a 01111. Contractor Date 7 3NU7-4-O �(� O IIX' ❑ I am exempt under S y. O Plan check fee u B.&P.C. for this reason. t, H Date: PERMIT ISSUING FEE $ Z Signature 7 TOTAL FEE OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and NAME Professions Code): I, as owner of the property, or my employees with ADDRESS. s oa wages as their sole compensation, will do the work and - �_ -»_ CITY TEL. NO. 3<(I: _9 e Ata the structure is not intended or offered for sale (Section +�-+ 7044, Business and Professions Code). { ITEMS •rTE j ❑ OWNER / ! t 1 7�1 t: I, as owner of the property, am exclusively contracting / ®d �J [ems p^ - with licensed contractors to construct the project (Sec- AMA ILDDRESS' ! AVS ��/v ( TOTAL 5 . 00 tion 7044, Business and Professions Code). """ .. �.• , CONSTRUCTION LENDING AGENCY ���n�N�Q[/ ,C!/' CITY TEL. NO. I hereby affirm that there Twu is a construction lending agency for --..-..----•.-- {';�y�')�, z(.l'_I the performance of the work for which this permit is issued CONTRACTOR (Sec. 3097, Civ. C.). ADDRESS 4/211 ,�)I Lender's Name _ Lender's Address CITY Of5ef-A t TEL. NO. � O� U J E0209 A i �'f v -- STATE I certify that I have read this application and state that the LICENSE NO. 62Qg6Z CLASS G above 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 po the above-mentioned p operty for inspectio, purposes. / G l SEE REVERSE FOR EXPLANATORY LANGUAGE junature of Applicant or eni Date ©s J WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT I,h�rgby effirm that I have a certificate of consent to self nsure,ora certificate of Workers'.Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING .or a cgrtified copy thereof (Sec. 3800, Lab. C.) 76A364C CE-818(REV. 10/81) 'Policy No. Company Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY ❑ Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING G� ( f �y a tion department. (PRINT OR TYPE ONLY) ADDRESS IF Date Applicant LOCALITYt t , NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST /�T/�n_ I/�/L COMPENSATION INSURANCE CROSS ST. � 4J�YV (This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO. PROCESSED BY the permit is for one hundred dollars ($100)or less.) AIR HANDLING UNIT, CFM I certify,that in the performance of the work for which this permit is issued, I shall not employ any person in any manner BOILER, BTU sous to become subject to the Worker 'Com Mforth- APPROVALS DATE INSPECTOR IGNATURE , �Lta- COMPRESSOR, BTUO Ov ROUGH Date pplicam NOTICE TO APPLICANT: If, after making thisVENTILATION SYSTEM FINAL Exemption, you should become subject to Compensation provisions of the Labor Code, yEVAPORATIVE COOLER VALIDATION with comply with such provisions or this permit shall be deemed revoked. FURNACE: FAU G AVITY LICENSED CONTRACTORS DECLARATION FLOOR BTU I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT (commencing with Section 7000) of Division 3 of the Business WALL and Professions Code,and my license is in full force and effect. Or License Number Lic. Class y Ilia.; (i Contractor Date O 1J U ❑ I am exempt under Sec. Plan check fee V UJB% 2 9 9 3t 5 A B.&P.C. for this reason' PERMIT ISSUING FEE $ Date: n # o o,o e o 8 TOTAL FEE Signature .1 ® x 4 6 2 5 OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT I hereby affirm that I am exempt from the Contractor's License ► -,o •0 4 6.2 5,63 . Law for the following reason (Section 7031.5, Business and NAME Professions Code): 06,20-88 ❑ I, as owner of the property, or my employees with ADDRESS wages as their sole compensation,will do the work and the structure is not intended or offered for sale(Section CITY TEL. NO. 7044, Business and Professions Code). . / OWNER. i / ` /1A , ❑ I, as owner of the property, am exclusively contracting V J " Ar with licensed contractors to construct the project (Sec- MAIL tion 7044, Business and Professions Code). ADDRESS e7 .710 CONSTRUCTION LENDING AGENCY CITYTEL. NSG I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued CONTRACTOR (Sec. 3097, Civ. C.). Lender's Name ADDRESS /0 CITY,J; TEL. NO. Lender's Address STATE LIC. I certify that L have read this application and state that the LICENSE NO. �ig'� CLASS above 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 up o thea ov e id rope y for inspection purposes. �� -'0 C7— 3,y SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent - Date 1�