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HomeMy Public PortalAbout6129-6131 GOLDEN WEST AVE_Mechanical__ I. WORKERS'CObIVENSATION DECLARATION 76A364C A p � I hereby affirm that I have a certificate of consent to self CE-818 (2-80) (nl L���/r 1 U�l FOR If� Uri uVU 0� insure, or a certificate of Workers'Compensation Insurance,of HEATING-V(ENT ILATING-Al R CONDITIONING a certified copy th-reof IS,r 380n,Lab.C.) / Policy No. �� Company /!r! E] Certified copy is hereby furnished. COUNTY OF L®$ ANGELES BUILDING AND SAFETY �l Certified copy is filed with the county building inspection BUILDING ///� /tee dPv/�rtme� t. sr� I�Offi APPLICAfiIT TO FILL IN ADDRESS (y (yfJ �N✓C.i/�— Date_�Lui��LApplicant �i 4� (PRINT OR TYPE ONLY) //lilt LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE COMPENSATION INSURANCE NEAREST ��f� } (This section need not be cennle:ed If the.work involved ABSORPTION UNIT, BTU CROSS ST. d by the permit is Cor one hundred doffary ($100) or less.) DISTRICT NO. PROCE SED By 0 I certify that in the performance of the work for which this I AIR HANDLING UNIT, FM ' N permit is issued, I shall not employ any person in any manner ) �Q �, S t © O cr so as to become subject to the Workers' Compensation Laws. BOILER, BT( Z7/^' / .� .y� �„ged APPROVALS DATE INSPECTOR'S SIGNATURE U Date_1& uppIIca.t 49 / (� COMPRESSOR, BTI, 71ey ~J W /1 ROUGH m �_ P Lu NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM z 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 deemed revoked. FURNACE: FAU GRAVITY LICENSED CONTRACTORS DECLARATION FLOOR: BTU — I hereby affirm that I am licensed under provisions of Chapter 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 n effect. 1L�avi�L /�/¢LK License Number_3�2-2-4-Lir.C1assda � Contractorate uZ' ❑ I am exempt from the licensing requirements as I am a licensed architect or c registered professional engineer Plan check fee 25%of above. acting in my professional capacity (Section 7051, Bus- iness and Professions Code)., Lic.or Reg.No. Date TOTAL FEE HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT Z� 5 8'8.5 A I hereby affirm that I am exempt from-the Contractor's NAME License Lav for the following reason (Section 7031.5, Busi- #io 0 0 0 0 8 ness and Professions Code): ADDRESS ' ❑ 1, as owner of the property, will do the work and the 2 0 1 4 a 5 Q CITY TEL. NO. structure is not intended or offered for sale (Section t0 0 1 4'$5 0.' 7044, Business and Professions Code). OWNER ❑ 1, as owner of the property, am exclusively contracting O a 2 6' 82 with licensed contractors to construct the project MAIL (Section 7044, Business and Professioiis Code). ADDRESS CONSTRUCTION LENDING AGENCY CITY TEL.NO. I hereby affirm that there is a construction lending agency CONTRACTOR �gTZr_ for the performance of the work for which this permit is issued (Sec. 3097,(�"v.r'). / Lender's Name_!Y�/v� /7� y� ADDRESS /BdfG� �AoK�SQS Lender's Address_Zj6s d__51, (r/ /�+d 6� / l3 CITY 1 L C � TEL. N0.�7� I certify that I have read this application and state that the STATE ZZ� LIC. 8� above information is correct.I agree to comply with all County LICENSE NO. 37- CLASS 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 ins r purposes Signature n`rermittee Date 364C WORKERS'COMPENSATION DECLARATION CEA 818 (2-80) G=14P F UC A T�O N FOR P E R 11%11 ff I hereby affirm that I have a' certificate of consent.:o self _ insure, or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec. 3800,Lab.C.) Policy No. Company COUNTY OF LOS ANGELES ES BUIL DING AND SAFETY Certified copy is hereby furnished. Certified copy is filed with the county building inspection FOR APPLICANT T® �9 L L INBUILDING >% department. ADD RESS �j!G�/� Date Applicant (PRINT OR TYPE ONLY) LOCALITY ` 46 CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE _ ,G COMPENSATION INSURANCE NEAREST CROSS ST. (This section need not be completed if the work involved • ABSORPTION UNIT, BTU d ��/" f O by the permit is for one hundred dollars ($100) oI less.) DISTRICT NO. PROCESSFD BY 0 I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM 'JC` permit is issued, I shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws. BOILER, BTU APPROVALS DATE INSPECTOR'S SIGNATURE U W Date Applicant COMPRESSOR,BTU N ROUGH NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM Z Exemption, you should become subject to the Workers' FINAL Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION with comply with such provisions or�this permit shall be deemed revoked. FURNACE: FAU GRAVITY LICENSED CONTRACTORS DECLARATION FLOOR: BTU I hereby affirm that 1 am licensed under provisions of Chapter 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 effect. -7 License Number-JLia Class—C—J0 \ Contractor 5;f} Date .� I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer Pian check fee 25%of above. acting in my professional capacity (Section 7051, Bus- iness and Professions Code). PERMIT ISSUgNG FEE $ Lic.or Reg.No. Date TOTAL FEE HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICA NT �z �--Ll� , l�,a E +� I hereby affirm that I am exempt from- the Contractor's NAM ` �g License Law for the following reason (Section 7031.5, Busi- - - —— P ness and Professions Code): ADDRESS Z �j �'5 9 0.7 A I, as owner of the property, will do the work and the #,I' ' structure is not intended or offered for sale (Section CITY �� — Tyy� TEL.NO. o 0 0 0 ° 7044, Business and Professions Code). LLp OWNE ye 2"° ° 33,50 I, as owner of the property, am exclusively contracting �— with licensed contractors to construct thep roJ ect MAIL x (Section 7044,.Business and Professions Code). . ADDRESS�O� ` fJ /��#u�.� ° ° O 3.3'5 0 5 CONSTRUCTION LENDING AGENCY CITY TEL NO. f^7/L j �'� 06.2.7—82 I hereby affirm that there is a construction lending agency ✓,T for the performance of the work for which this permit is CONTRACTOR issued(Sec. 3097,Civ.C.). Lender's Name ADDRESSk.3 G` 00 W_///p Lender's Address CITY 1� TEL.NO. � /_�1� I certifythat I have read this application and state that the / C� pp STATE �/'/ 7�7 LIC. �p above information rect. ag comply with all County LICENSE NO&612-77 2- CLASS J ordinances tate laws 6gulating ting, Ventilating and Air Con Toning, and ty authorirepresentatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE Count to ."ter ¢p'. ne ei - entioned property, for u1spec Ito .` Signature o e*..tittee Date