HomeMy Public PortalAbout6312 GOLDEN WEST AVE_Mechanical__ WOQKERS'COMPENSATION DECLARATION r APPLICATION FOR PERMIT
I hereby affirm that I have a certificate of consent to self
Insure, or a certlflcate of Workers'Compensation I surance, HEATING - VENTILATING - AIR CONDITIONING
or a certified co thereof (Sec. 3800, Lab.
(E-918(REV. 10/81)
Policy Compan
Ct fled copy Is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy Is filed with the co my build�11 - FOR APPLICANT TO FILL IN BUILDING
ti d men,. ADDRESS
(PRINT OR TYPE ONLY)
Date Applicant LOCALITY tom^ t
TYPE Of APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OFEXEM N F WORKERS' NEAREST
COMPENSATION IN CE C5
(T-hIs section need not be comp) if the work Involved by ABSORPTION UNIT, BTU oISTZIcr Tao. BY
the permit ts for one-hundred dollars(=100)or.le".) AIR HANDLING UNIT, CFM �j
I certify that In the performance of the work for which this (5C C,
permit Is Issued, I shall not employ any person In any manner
-so as to become subject to the Workers'Compensation Laws. BOILER, BTU AaPaov,LS DATE rtE
ROUGH
Date Applicant
NOTICE TO APPLICANT: if, after making this Certificate of vwnLATION SYSTEM FINAL
Exemption, you should become subject to the Workers' 72
Compepsation prbvlslons of the Labor Code, you.must forth- EVAPORATIVE COOLER VALIDA
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU
LICENSED CONTRACTORS DECLARATION FLOOR BTU (/
I hereby affirm that I am licensed under provisions of Chapter 9 IF HEATER: SUSPE�
`(commencing with Section 7000) of Division 3 of the Business WALL
and Professions Code,and my license Is In full force
/and
'ef�fec�t.
License Uumber Ic Class s+
Q , �
Date /
I am mpt under Plan check fee a
h
B. .C. for this r n 4 . PERMIT ISSUING FEE $ Z
- Date. TOTAL FEE
Signature
1 3 Q 4 A
OWNER-BUILQER DECLARATION PLAN CHECK APPLICANT
EC
I hereby affirm that I am exempt from the Contractor's License # o o o o e 8
Law for the following reason (Sectlon 7031.5, Business and NAME
Professlom Code):' I o o 3 Q 5,0
❑ I, as owner of the property, or my employees with ADDRESS'
wages as their sole compensation,will do the work and CITY TEL NO • -.- 3 Q 5 0 iS
the structure Is not Intended or offered for sale(Section
7044,Business and Professions Code). 2,1 2 i�8 8
OWNE
❑ I, as owner of the property, am exclusively contracting oe
with licensed contractors to construct the project (Sec-. MAIL
tion 7044, Business and Professions Code).
CONSTRUCTION.LENDING AGENCYcrrY TR NO.
I hereby affirm that there Is a construction lending agency for '
the performance of the work for which this permit Is Issued CONTRACTOR
(Sec. 3097, CN. C.).
ADt?RE '
Lenders Name
CJTY \ TEL NO. _tm
Lenders Address
STA UC
I certify that 1 have read this application and state that the LICENSE NO. CLASS
above Inforrnation Is correct. I agree to comply with all County
ordlnancez ohd State laws relating to building construction,
and hereby authorize representat of this County to enter
upon th vo- ntloned pr or Inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of cant or Agent e