HomeMy Public PortalAbout6201-6201 1/2 GOLDEN WEST AVE_Mechanical__ WORKERS' COMPENSATION DECLARATION APPLICATION FOR PERMIT
I Ifereby�afItrm that I have a certtf�cate of consent to self
Il
sure; gr a certificate of Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof (Sec 3800, Lab C ) 76A364C
JC 7�? �� C�� CE-818-(REV 10/81) j
Policy No �d uCo pony // COUNTY-OF LOS ANGELES'- BUILDING AND SAFETY
Certified copy is hereby furnished
Certified copy;is filed with the.county building inspec- FOR-APPLICANT TO FILL IN BUILDING
tion deportment ADDRESS
P (PRINT OR TYPE ONLY)
Date 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 PROCESSED BY
the permit is for one•hundred,dollors ($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
'so as to become sublect,to the Workers'Compensation Laws BOILER,.BTU APPROVALS DATE INS OR'S'SIGNATURE
Date Applicant COMPRESSOR, BTU, ROUGH
NOTICE TO APPLICANT If, after making this Cerhficate of -VENTILATION SYSTEM FINAL l
Exemption, you should become subject to the, Workers'
-C-ompensatiorrprovisions of the-Labor C-ode�you'musYforih= - EVAPORATIVE COOLER �� - VALIDATI N
with comply with such provisions or this permit shall be
deemed revoked FURNACE FAU GRAVITY D O
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER SUSPENDED ONIT
LL
(commencing with Section 7000) of Division 3 of the Business WA
and Professions Code, and my license is in full force and effect _- _ 0.=
License Number ` Lic Class ^ / S¢ 0
Contractor EAi-6 AL7 ii:ite 0
❑ V
I am exempt under,Sec 1 U
Plan check fee N
B &P C for this reason PERMIT ISSUING FEE $ Z
e � •
Sfit gnat a TOTAL-FEE
93a5'A
7N 5RNER-BUIL E CLARATION HECK APPLICANT
'I hereby of irm that I am exempt from the Contractor's License +o e 0}i to 8
Law for the following reason (Section 7031 5, Business and NAME �/ LS
Professions Code) j � •- , T;o o 4 4.5 0
ADDRESS U
❑ I, as owner of the property, or my employees with /
wages as their sole compen"sahon,will do the work and x'TEL NO oto ro 4 4, 505
the structure is not intended or offered for sole(Section CITY ��(� / ZLr
7044, Business and Professions Code) O 10 8`" 8 8
❑ 1, as owner of the property, am exclusively contracting OWNER S GL G�
with licensed contractors to construct the project (Sec- MAIL
tion 7044, Business and Professions Code) ADDRESS
CONSTRUCTION LENDING AGENCY CITY EL NO
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 ) -
' ADDRESS
Lender's Nam_e
CITY _ _ TEL NO. -
Lender's Address +
STATE' 7 LIC
I certify that I have read This application and state that the LICENSE NO �* CLASS -'
above information is correct I'agree to comply with all County
ordinances and State jaws luting to building construction,
an >ere horize re es atives of this County to enter "
pan abo -me do ed perty for inspection purposes SEE'REVERSE FOR EXPLANATORY LANGUAGE _
nature of Applicant o Ag t , Date - - - - - - -- - - - - "