HomeMy Public PortalAbout6243 GOLDEN WEST AVE_Mechanical__ WORKER'S have
a certificate
of consent
to 76A346DPW9/89 APPLICATION FOR PERMIT LIME GREEN
• 76A364C
I hereby affirn2 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.
❑ Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN BUILDING 6
2
department. (PRINT OR TYPE ONLY) ADDRESS
LOCALITY '
Date Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
CROSS
COMPENSATION INSURANCE
ABSORPTION UNIT,BTU ASSESSOR
•
(This section need not be completed if the work involved by the MAP BOOK � � _ PAGEe�g/ PARCEL
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
- - DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU
become subject to the Workers' Compensation Laws.
COMPRESSOR,BTU -
� - APPROVALS DATE � INSPECTOR'S SIGNATURE
Date - - App I- VENTILATION SYSTEM
NOTIC TO ICANT: after ting thl Certificate of ROUGH
Exemption,you should become subject to the Workers'.Compensation
EVAPORATIVE COOLER FINAL
provisions of the Labor Code, you must forthwith comply with such
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED I UNIT
'(commencing with Section 7000) of Division 3 of the Business and HEATER: WALL a
Professions Code;and my license is in full force and effect.
.....� '1•I O�
License Number 4alLic.Class — i�l / 7 113.38
a.
Contract o J Date 1 ITE!€j❑ V
Plan check fee I am exempt under Sec. TOTAL 13 w 33 �
B.&P.C.for this reason PERMIT ISSUING FEE$ 7 CHECK 113. S O
Date: TOTAL FEE . CHANGE. .. .I_fl� .d
....................._._ ...
Signature co
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT "' •-��� q _
I hereby affirm that I am exempt from the Contractor's License Law NAME L{JSJ0' 0001 1/29/93
for the following reason (Section 7031.5, Business and Professions �71 1 tr) il�
Code): ADDRESS
24
❑ I, as owner of the property, or my employees with wages
as their sole compensation, will do the work and the CITY TEL.NO.
structure is not intended or offered for sale(Section 7044,
Business and Professions;Code). OWNER.
❑ I, as owner of the property, am exclusively contracting MAIL
with licensed contractors to construct the project(Sec- ADDRESS
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY TEL.NO.
I hereby'affIrm that there is a construction lending agency for CONTRACTOR
the performance of the work for which this permit Is issued
(Sec.3097,Civ. C.).
ADDRESS
Lender's Name V
CITY TEL.NO.� _
Lender's Address STATE LIC.
I certify that I 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
property for inspec'bn"purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
A R OF PPLICANT ORA GENT ' i" A