HomeMy Public PortalAbout6245 GOLDEN WEST AVE_Mechanical__ WONKER'S COMPENSATION DECLARATION 20-0046 DPW 9/89
76A364C APPLICATION FOR PERMIT
.LIME GREEN.-
I hereby affirm that I have a certificate of consent to self insure,
or acertificate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING
copy theteof(Sec.3800 Lab. C.) 11
Policy No. Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV..
Certified copy is hereby furnished.
El Certified copy is filed with the count building inspection FOR APPLICANT TO FILL IN BUILDING
department. y g p (PRINT OR TYPE ONLY) ADDRESS
Date' Applicant LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS" NEAREST
CROSS ST.
COMPENSATION INSURANCE
' ABSORPTION UNIT,BTU ASSESSOR v - -
(This section need not be completed if the work involved by the MAP BOOK ,5,;O S PAGE 0. PARCEL Q��
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit n
is issued, I shall not employ any person in any manner so as to I BOILER,BTU
become subject to the Workers'Compensation Laws: C�IJ
COMPRESSOR,BTU .
APPROVALS DATE INSPECTOR'S SIGNATURE
DateFA Ad,11�2Applic t VENTILATION SYSTEM.
NOTrC qTO'IPO 171 CANT: If,,aft making Is Certificate of ROUGH
Exemption,you should become subject to the orkers'Compensation EVAPORATIVE COOLER
provisions of,the Labor Code, you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY _
LICENSED CONTRACTORS DECLARATION FLOOR BTU
J PEED
VALIDATIONS.
. .... ....., n 4
I hereby affirm that am licensed under provisions of Chapter 9 SUSNDUNIT •- p a -
(commencing with Section 7000) of Division 3 of the Business and HEATER: WALL ACCT
Professions.Code,and my license is in full force and effect. 3307
113.38
_ 4AX2
S
0 1 ITEM'
License Number Lic.Class A?-0 3 _
f Pol. TOTAL 11.3 m::� 0...o
Cont cto Date Ja iL a JO
Plan check fee
CHECK ca
I am exempt er Sec. - �) ($
CHANGE � o
B.&P.C.for this reason PERMIT ISSUING FEE$
Date: Q _. _ _ V
Signature TOTAL FEE Q .0000_0001 1/29 j,,1 K
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT ,]-Irl q hMi i0 y1 Z
I hereby affirm that I am exempt from the Contractor's License Law NAME L t itltl _
for the following reason (Section 7031.5, Business and Professions
Code): ADDRESS --
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 contractofs to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code).
CITY TEL.NO.
CONSTRUCTION LENDING AGENCY
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
CITY TEL.NO.
Lender's Address STATE LIC.
certify that I have read this application and state that the above LICENSE NO. CLASS e
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 inspectio -pur ses. SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNrAE @T AI5#LicAPVFrAGMT AT