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Home My Public Portal About6126 GOLDEN WEST AVE_Mechanical__ WORKERS' COMPENSATION DECLARATION APPLICATION FOR PERMIT I hereby affirm that I have a certificate of consent to sekf insure, or a certificate of Workers' Co(npensatioh Insurance, ' HEATING - VENTILATING - AIR CONDITIONING or a cerfifi d o y t ereof (Sec. 3800, ab. C�) 76A364C 20-0046 DPW 9/88 ❑cy No. ) 0 Company Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY Certified copy is filed with the county buildin inspec- FOR APPLICANT TO FILL IN BUILDING ( tion department. (PRINT OR TYPE ONLY) ADDRESS Date I Applicant LOCALITY NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST COMPENSATION INSURANCE CROSS ST. (This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO. U PROCESS) 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 J f permit is issued, I shall not employ any person in any manner BTU J so as to become subject to the Workers' Compensation LOWS. BOILER, APPROVALS DATE INSPECTOR'S iG ATURE (/t Date Applicant If COMPRESSOR, BTU a ROUGH f� ' NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL O Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALID TIO with comply with such provisions or this permit shall be deem- ed revoked. FURNACE: FAU GRAVITY r� 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 m license is in full force and effect. License Number 1 Lic. Class �-� rto D 917 /C n , O ( (r OLJ U Contractor Date ❑ I am ex pt under Se O Plan check fee B.BP.C. for this reason D CL PERMIT ISSUING FEE $ H Date: z Signature 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 y ❑ I, as owner of The property, or my employees with ADDRESS ACCT■ir tp -}� wages as their sole compensation, will do the work and CITY TEL. NO. 330 77'r�1 the structure is not intended or offered for sale(Section `� 7044, Business and Professions Code). OWNER 1. ITEM I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec- MAIL TOTAL............ 4r` -75 tion 7044, Business and Professions Code). ADDRESS � `t 49 �C CONSTRUCTION LENDING AGENCY CITY TEL. NO. CHECK 1 hereby affirm that there is a construction lending agency for , CHANGE .011 the performance of the work for which this permit is issued CONTRACTOR (Sec. 3097, Civ. C.). ADDRESS Lender's Name 0000-0001 11/ 1/87 Lender's Address CITY TEL. NO. 6503 1 AM10:4 1 certifythat I have read this application and state that the STATE LIC. PF above information is correct. I agree To comply with all County LICENSE NO. CLASS ordinances and State laws relating to building construction, and hereby aut orize representatives of this County to enter upon t o -mention property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE gnature o Applicant or Agent Date ©s