HomeMy Public PortalAbout6344 GOLDEN WEST AVE_Mechanical__ WORKERS' COMPENSATION DECLARATION APPLICATION FOR PERMIT
� I hereby affirm that I have a certffl4ate of consent to self '
Insure, or a certificate of Workers nsaUon Insuranca, HEATING - VENTILATING - AIR ONDITIONING
or a copy thgreof (Sec , ab. C.)
J DPW 9,,M-
Poll G� Comps
Certified copy Is hereby furnish . COUNTY OF LOS ANGELES BUILDING AND SAFETY
certified copy E��24rns filed with a co my Ilding'Irispec- FOR APPLICANT TO FILL IN �R�
(PRINT OR TYPE ONLY)
ze
Data
App l i LOCALITY
NO. TYPE OF APPLIANCE OR KQUIPMENT FEl
CERTIFICATE OF ON FROM RS' QST
COAAPEIJSATION INSU CROSS ST.
(This section rm"not be cam �t*d M the work In"Ived by ' .AB50RF1lON UNIT, BTU NSTRKT NO. PRp�ssm�BY
the PaIrmilt Is for cPhe hundred d 1IL{=100) or loss.)
HANDLING
I certify that In the pr;rformarlce of the AIR UNIT, CFM
work for which this
*mit Is Issued, I shall not employ any,person In any manner
so as to become subject to the Workers'Compensation Laws. BOILER, BTU — APPROVALS TF NsPEcroR-s SIGNATURE.
COMPRESSOR, B o p _ ROUGH
Date Applicant
NE a TO APPLICANT: If, after making this Certificate of VE2,TII_AT10N SYSTEM F1 NAL
-Exemption, you should become subject to the Worken '
VV V
Compensatron provlslons of..the Labor Code, you mutt forth- EVAPOI ATVE COOLER VALIbAlribu
with comwith such provisions or this permit shall,be claim-
ed revoked,p)y FURNACE: FAU GRAVITY _
LICENSED CONTRACTORS DECLARATION FLOOR BTU-
I hereby Affirm that i am Ilcerned under provisions of Chapter 9 HEATER: SUSPENDED UNIT
(commencing with$action 7000)'of DWlslon 3 of the Business WALL
and Professions Code,and my licenseis In full force and affect.
Ucehse N c. CI , 4
O.
Gontr Date _ v. 0
exempt"u
Sec Plan check fee ACGT.T
$.BPiC'_ for..thjs reasenPERMIT ISSUING FEE j 3 _ .3M7 tie _25.cc
Z
Date: 1 1TGl k7
Signature TOTAL FEE
TOTAL. -- 25,00
OWNER-BUILDER DECLARATION PLAN-aHECK APPLICANT -
I hereby affirm that I am exempt from the Contractors License
CH .
Law for the followln$ reason (Section 7031.5, Business and NAME
Professions Code):
AD DRESS
❑ I, as owner of-the.Property, or my employees with `
wages as their sole compensation,will do the work and CTTY TEL. NO # 9/17190
the structure Is not Intended or offered for sale(Section ++��arr��
7044, Business anc[Professions Code).' .:7111 1 M10:58
❑ I, as owner of the property, am exclusively contracting
with licensed contractors to const-ruct-the project (Sec- MAIL.
tlon 7041, Business and Professions Code).
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 CONTACTOR
(Sec. 3097, Civ. C.).
ADDRESSloo
Lenders Name
CITY TEL NO ,
Lenders Address
I certify that I have read this appllcatlon and state that the ILKIN' SE NO y TATE1' CLASS - -
above Information Is correct. I agree to comply with all Count).
ordinances and State laws relating to building construction, `
OcfApp4can
uth representatives of thls.County to enter
v ntloned property for IrstIon purposes."
SEE REVERSE FOR EXPLANATORY LANGUAGE
Agent