HomeMy Public PortalAbout6257 GOLDEN WEST AVE_Mechanical__ WORKERS'COMPENSATION DECLARA fIG1Al. ^ 'CE=`88 12-Ba). APPLICATION FOR PERMIT f�
I hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers'Compensation Insurance,or HEATING;-VENTILATING-AIR CONDITIONING IL JI
a certified copy thereof(Sec. 3800,Lab.C.)
Policy No. Company
Certified copy is hereby furnished. -
COUNTY OF LOS ANGELES BUILDINQ AND SAFETY
Certified copy is,filed wltb the county building Inspection. BUILDING
deparfmont. FOR APPLICANT TO.FILL IN`
Data Applicant (PRINT OR TYPE ONLY)
ADDRESS
• 1
LOCALITY
CERTiFICATE,OF EXEMPTION FROM WORKERS'
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
COMPENSATION INSURANCE NEAREST
('Iltis segtlon need not be cbrrtpleted If the work involved ABSORPTION UNIT, BTU CROSS sT..
by the permit is for one hu Bred dbHm (5100) or leas.) 019TRICT t+O. PROCESSED v 8
f certify th}t in the performs cd of the work for'which this AIR HANDLIN-G UNIT CFM n 2
permit b ued, 1 shah ngti o )toy any.pe In any manner
so as to ec0[�e subject'fo t Wofbbjtact
' Co satlon Laws. BOILER BTU
a •APPROVALS DATE IttaP£CTO R'S 5 I NATU"
to pplican COMPRESSOR BTU
NOT E TO APPLICANT: If, afterthis Certmcste of ROUGH SfZ
Exemption, g VENTILATION SYSTEM _
p you should becorpe to the Wgrkera' FIN-.4L �—
Compensation provfsioni of the Labor Code, you must forth-
with comply With such provisions or this permit shall be EVAPORATIVE COOLER VALIDATION
deemed revoked.
FURNACE: FAU GRAVITY
LICENSED CONTRACTOR.9•DECLARATION FLOOR: BTU
I hereby affirm that I am llcensdd under prpvtsloru'bf Chapter HEATER: NOED. UNIT
9 (commencing with Sect Con 7000) of Dh'fsion"3 of the Busi- W1AL2
ness and Professions Code, and my license is 1n full force and
effect.
License Number_ Lic.Class
Contractor_ Data
Q1 am exempt from the licensing requirements as I am e
licensed architect or a -registered ptvfessional engineer Plancheck fee 2fi`j(i•of above.
acting In my-professlona'i capacity (,Section 7061, Bus-
iness and Profes4ons Code). PERMIT-ISSUING FEE $
LIc.or Rea.No. Date TOTAL FEE
HOME OWNER-BUELOER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from-the.Contractor's NAME f 5•2'j7.Q A '
License Law for the followtn& reason (Section 7031'.5, Bust- r ,
nessandProfessionsCode): ADDRESS # • •I• • •,8
1, as owner of the property, will do the work and the t
structure Is not Intended or offered for sale (Section CITY TEL. NO. 2 • •`� ;50r
7044, Business and Professlods Code). L
1, as owner of the property, am exclusively corttracting OWNER. •,•1 ,235,0
with licensedcontractors to construct the project MAIL 7
(Section 704-4,Business and ProfessioAs Code). ADDRESS �'14'a 0 j-8 2
CONSTRUCTION LENDING AGENCY CITY TEL..NO. 3 -
I hereby affirm that there is a, construction lending agency
for the performance 'of the work for which this permit Is CONTRACT R a
issued (Sec. 3097,Civ.C.).
Lender's Name ADDRESS
Lender's Address CITY TEL.NO.
I certify that I have read this application end state that the STATE LIC.
above information b correct.I agree to comply with all County NO. CLASS
ordinances and State laws regulating Neating, Ventilating and
4AIrndttioning, and hereby authorize representatives of this SEE,REVERSE FOR EXPLANATORY LANGUAGE
o enter upo a move-mentioned pr rty for
purpof rmlttee Date