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HomeMy Public PortalAbout6143 GOLDEN WEST AVE_Mechanical__ JVORKERS'COMPENSATION DECLARATION CEA 868 (2-SQ) \ p p b�C�Q Ti 0 O N [s O R p E R� u I hereby affirm that I have a certificate of consent to self insure, ori_-c rN1q.ate of Workers'Compensation Insurance,or HFEA 'pNG_V ENTII_ATI(r G-AIR OONDOTIOfn9OMG a certif,,5d copy thereof(Sec. 3800,Lab. --��^��C..) Policy N.5—t9_531.Company�7a_ � _ !���r Certified copy is hereby furnished. COUNTY OF Los ANGELES BUILDING A�I¢�SAFETY xi �C-ertified copy is filed w/.n .he county ' uitd ng inspection �®� �ppLICAI�T f0 FILL II\I BUILDINGepartment �Q� �(J I"D—ate_1D D_T-;43 Applicar W I �-1 FF (PRINT OR TYPE ONLY) ADDRESS _ LOCALITY PQ CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE _w`�'./ COMPENSATION INSURANCE NEAREST >_ (This section need not be completed if the work involved ABSORPTION UNIT, BTU CROSS ST. • � • d by the permit is for one hundred dollars ($100) or less.) DISTRICT NO. PROCESS sv U I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM permit is issued, I shall not employ any person in any manner 0 so as to become subject to the Workers' Compensation Laws. BOILER, BTU �/ APPROVALS DATE INSPECTOR'S SIGNATURE `U Date - Applicant COMPRESSOR, BTU_l���� 74 40 ROUGH 0- NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM _!2 Z Exemption, you should .become subject to the Workers' FINAL !! Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION with comply with such provisions or this permit shall be deemed revoked. FURNACE: FAU RAVITY LICENSED CONTRACTORS DECLARATION FLOOR: BTU -OQOQ I hereby affirm that I am licensed under provisions of Chapter + HEATER: SUSPENDED UNIT v 9 (commencing with Section 7000)of Division 3 of the Busi- I WALL ness and Professions Code, an'd my license is in full force and i^ICC'T. effect. L)L �1 ,f�v.� e a_R License DNib:.eAl�� 8 Q Lie.Class v i ITEMS Contras �(/wY�ilate l0� /�`� ,. I' Q A 7 I am exempt from the licensing requirements as I am a I 3�lTrtL �a' 15 licensed architect or a registered professionat engineer i plan check fee 25%of above. ;, acting in my professional capacity (Section 7051, Bus- I E,'O��' mess and Professions Code). PERMIT ISSUING FEE$ F-= ANGE Lie.or Reg.No. Date T®TAL I=EE HOME OWNER-BUILDER DECLARATION ! PLAN CHECK APPLICANT tjEil'1 #si lji f r.f.7, I hereby affirm that I am exempt from- the Contractor's I NAME — ,-, , License Law for the following reason (Section 7031.5, Busi- 0•''3- ,*3 i 1 AM ness and Professions Code): ADDRESS El1, as owner of the property, will do the work and the I " structure is not intended or offered for sale (Section I CITY TEL. NO. 7044, Business and Professions Code). OWNER I, as owner of the property, am exclusively contracting with licensed contractors to .construct the project MAIL (Section 7044, Business and Professions Code). I ADDRESS CONSTRUCTION LENDING AGENCY CITY TEL.NO.� s� /c,/� I hereby affirm that there is a construction lending agency CONTRACTOR for the performance of the work for which this permit is tel/ issued (Sec. 3097,Civ.C.).Lender's Name ADDRESS esu- _ -2- Lender's Lender's Address CITO /,-, ­� le A TEL.NO. I certify that I have read this application and state that the STATE �� �y©/ LIC. above information is correct.I agree'to comply with all County LICENSE NO. / CLASS l.• �' ordinances and State laws regulating Heating, Ventilating and Air Conditioning,and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE County to enter uYK on the above-mentioned property for e i inspi p rpo- Signature of Permittee Date 16N W!?Pthat I have a certificate of consent to 76A346DPW9/69 APPLICATION FOR PERMIT LIME GREEN. 76A364C I hgrely afttm that I have a certificate of consent to self insure, or a certificate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING copy thereof(Sec.3800 Lab. C.) Policy No. Company COUNTY OF LOS ANGELES .' DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV. ❑ Certified copy is hereby furnished: 1 ❑ Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN BUILDING UD ESS��fJj department. (PRINT OR TYPE ONLY) 'Date Applicant LOCALITY NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST CROSS ST COMPENSATION INSURANCE ABSORPTION UNIT,BTU ASSESSOR (This section need not be completed if the work involved by the MAP BOOK PAGE�� PARCE�O permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM r� ' DISTRICT NO. PROCESSED BY I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to BOILER,BTU O become subject to the Workers' Compensation Laws. D d COMPRESSOR,BTU -0 Q Z_40 - APPROVALS DATE INSPECTOR'S SIGNATURE Date Applicant VENTILATION SYSTEM NOTICE TO APPLICANT: If, after making this Certificate of ROUGH yZ Exemption,you shouldbecome subject to the Workers'Compensation EVAPORATIVE COOLER provisions of the Labor Code, you must forthwith comply with such FINAL provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY. LICENSED CONTRACTORS DECLARATION. FLOOR BTU VALIDATION 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 and WALL Professions Code,and,my license is in full force and effect. n License Number Lic._Class 14 (l�O 6� O , } 0- Contractor Contractor Date 0 ❑ I am exempt under Sec. Plan Check.fee V Q B.&P.C.for this reason PERMIT ISSUING FEEti O Date: TOTAL FEE `: W Signature d OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT j, Z I hereby affirm that I am exempt from the Contractor's License Law NAME »r» for the following reason (Section 7031.5, Business and Professions , t: Code): ADDRESS � -• t. . ❑• I, as owner of the property, or my employees with wages as their sole compensation, will do the work and the CITY TEL.NO. w structure is not intended or offered for sale (Section 7044, .;. `s t.4 Business and Professions Code). OWNERO 7d I, as owner of the property, am exclusively contracting MAIL '''(t�'?"•' with licensed contractors to construct the project (Sec- DRESS/01/1543/ V, � tion 7044, Business and Professions Code). Q CONSTRUCTION LENDING AGENCY CITY TEL.NO. �78 ^TSaj«t y Y •.j.•w I hereby affirm that there is a construction lending agency for CONTRACTOR ' the performance of the work for which this permit Is issued , f.Y.':5._ "' (Sec.3097,Civ. C.). ADDRESS Lender's Name CITY TEL.NO. Lender's Address I certify that IFATE LIC. have read this application and state that the above LICENSE NO. CLASS 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 upon the above-mentioned propert r inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE SIGNATURE OF APPLICANT OR AGENT DATE '