HomeMy Public PortalAbout6244 GOLDEN WEST AVE_Mechanical__ a
WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
rl. hereby affirm that I have a certificate of consent to self '
insure, or a certificate of Workers' Compensation Insurance, 76A364C HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof (Sec. 3800, Lab. C.)
CE-818(REV. 10/81)
Policy No. Company
Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
❑ Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING A
tion department. (PRINT OR TYPE ONLY) ADDRESS
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 dollars ($100)or less.) AIR HANDLING UNIT, CFM
I certify that in the performance of the work for which this c V v
permit is issued, I shall not employ any person in any manner BOILER, BTU
so as to become subject to the Wor ers' 'ompens ion Laws. APPROVALS DATE S ECTOR'S SIG ATURE
n AM
Date 4'2—8/ Applicant -- - ( COMPRESSOR, BTU oov Idlov ROUGH
J
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATI N
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU W1_ GRAVITY /1 /��
LICENSED CONTRACTORS DECLARATION FLOOR BTU _06 v /0 V
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 my license is in full force and effect.
License Number 4A71 -60 Lic. Class (1'2d , V
Contractor Date ;2679.8A
❑ 1 am exempt under Sec. # o o o o,o 8 Lu
Plan check fee �
B.BP.C. for this reason .( o 51.5.0
PERMIT ISSUING FEE $
Dater
Signature TOTAL FEE 0 0 0 5 15 O v
OWNER-BUILDER DECLARATION PAN CHECK APPLICANT, O 103-87
I hereby affirm that I am exempt from the Contractor's License ►
Law for the following reason (Section 7031.5, Business and NAME1�sr�Q
Professions Code): _
❑ I, as owner of the property, or my employees with ADDRESS 6.L Golc6cj
wages as their sole compensation,will-do the work and
the structure is not intended or offered for sale(Section 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 (Sec- MAIL
tion 7044, Business and Professions Code). ADDRESS
CONSTRUCTION LENDING AGENCY CITY TEL. NO.
I hereby affirm that there is a construction lending agency for ,
the performance of the work for which this permit is issued CONTRACTOR '� —;Mi
(Sec. 3097, Civ. C.).' 1
Lender's Name ADDRESS
CITY TEL. NO. 57 _Jq�:{
Lender's Address ASTATE /' ✓^! �1 J
I certify that I have read this application and state that the LICENSE NO. 4971 Z(o CLASS 0-20
above information is correct. I agree to comply with all County
ordinances and State laws relating to building construction,
a hereby author' a representatives of this County to enter
n th ve-m ntioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date -