HomeMy Public PortalAbout6247 GOLDEN WEST AVE_Mechanical__ WDR>¢A'B CO#G'ETd3ATION DECLJ1FiATION 818Q
1•hp�@by afflrmdhat I have a certlflopte of consent to self Insure, APPLICATION FOR PERMIT LIME- GREEN'
or a certhloate of Worker's Compensat)on Insurance, or a certifled ' HEATING-VENT1LATlt�a-AIR CONDITIONING
rxpy thereof(Seo.3800 Lab.C.)
Policy No. Company COUNTY OF LOS ANGELES DEPT,OF PUBLIC WORKS BUILDING AND SAFETY,DIV LJ
^0 CgGtf3ed copy la hot" tumished.
CertHW copy Is Med-whh:ths ootmty buftding Inspection FOR AP CANT TO FILL IN BUIMM
i
dn.
(PRNT OR TYPE 0NL.1) AD°
De3e A?p00ent NO. TYPE OF APPLW4Ce 0r I COtJIPAIENT FFFTM
Q=FiCATE OF B7 EMPT"FROM WOtRKBW CF008a ST.
COMPENJ T)DN INSURANCEABSiPT1
C 0N UMt SFIi
(Thls section need not be oompletad Jf the work Involved by the_ NAP BOOK p� PAGE tW PARCEL Q
.p•rmtt is for one hundred donars(0100)or lase.) AIR HANDuNauI,&
osrrrrct Pnocae®w
t,certify that In the perforihamce of the Work-for Which thli permtf
Is Isauno
ad, I shaiL t emploX any person In'ahy manner sioas to., BTU
beoome,subject to the Workers' CompenAation Laws. ��
CON BTU
Date APPROVALS .- oITE ueP YTOF gsuwATtPe
VB1]IILAMN SYSTEM
NOTIC L ANT. If, aft makln 41.N7 ■ta of ROUpR
Exempt] should beowne subject to.thq orkers'Compermation EVAPOFIATIVE COOL
provisions of the Labor Code, pp must wtih comply with such FNAs- _
provisions or this pernift&hall be deemed rewked. FURNACE FAU ORAVfG1l
VCENSM CONI'RACTOfi$DECLAAATION ; d FLOOR BTU VALID,—
—
I hereby &Mrm that I.am Ilceneed under provision& oT Chapter Q_. HEATEF SUSPE7JDED UNIT '
(oommenglnd wtth SeaUon 7000) of'Dtvl@lon 3 of the Bu&Inc�ss and WAIA
-Prafbielond'Cods,and my,llo�rlee Is In full force and'effect.. -
IJcerue Num bar Lic.Class 4 LL
°°te - ,a, 7 113.E "$
I em nde�S.,
PISS check fee. -- y
B BP.C.for thfe reason PE AIT_IS$UING FEE ITEMS- Q
Dae: TOTAL FEE TOTAL •113 38.
slgm.e , 113.3$ w
OWNI73 BUILDffI DECt AFiAT#(?IJ PLAN q IEOK APPLK Mfr (• { (� fa/)
I hereby affirm that I am exempt from the Contractor's License raw N,wE
for the tollgwing reason (Section 7031.6, Business and Professions- +
Code):
ADDRESS , ;y-.�y��yyL
n I, am owner of the property, or my employees with wapbs `000 —0001 1/29/93
as their sole compensation,'will do the work and the CITY TEL NO. i ��+:
stiuoture Is not Intended or offered for sale (Seotlon 7044, r 1 1
23
Business and Profesefone Code). OWNEFI F•
I, as owner of the, prope(ty, am exclusively contracting
A.
With licensed contractors to aonstruot the project (Sec- APDRE88
tion 7044,Buslneas and Proiestlbns Code).
CONSTRUCTION LENDING AGENCY.
CITY TEL NO.
I hereby affirm that there L& a construction IendlnQ a envy for � � r
the performance of the work for which this permit Is issued
(Sao.3097,Cfv.C.)., ► - i.yi ;,,
ADORE88
j_ender's Name
Crry TEL NO.
Lender'&Address
L certffy that r have read tlib appllcaYlon and atate that the above LLiCElaM NO. UA88 _.
ttforrnatiw is correct. I egree to compty with all County ordlnwicee
and State k ft rate rig to biding construction,and hereby euttuxtre
representatives of thle C-OVhty to ariter upon the above-mentioned
property for Inepe on purpoeee, SEE REVEi$E FQR EXPLANATORY LJ4NGUABE