HomeMy Public PortalAbout5019 FARAGO AVE_Mechanical__ r_ WORKERS COMPENSATION DECLARATION
hereby affirm that i 1-rive a certificate of consent to self APPLICATION FOR PERMIT
Insure or a certificate of Worke Compensation Insurance 76A364C HEATING VENTILATING AIR CONDITIONING
or a certified copy thereof(Sec 3800 Lab C )
CE 818(REV 10/81)
Policy No Company
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Certified copy is hereby furnished COUNTY OF LOS ANGELES BUILDING AND SAFETY
❑ Certified copy Is filed with the county building Inspec FOR APPLICANT TO FILL IN BUILDING � �0
tion department (PRINT OR TYPE ONLY) ADDRESS V A
Date Applicant LOCALITY
NO TYPE OF APPLIANCE OR EQUIPMENT FEE ��� r i•�
CERTIFICATE OF EXEMPTION FROM WORKERS NEAREST
COMPENSATION INSURANCE CROSS ST
(This section need not be completed if the work involved by ABSORPTION UNIT BTU DISTRICT NO PROC
the permit is for one hundred dollars($100)or less) t
1 certify that In the performance of the work for which this AIR HANDLING UNIT CFM
t
permit Is Issued I shall not employ any person In any manner BOILER BTU
so as to become subject to the Workers Compensation Laws APPROVALS DATE INP TOR 5 SIGNATURE
Date 3- OApplicantIlAr7-VZ61COMPRESSOR BTU An ROUGH _
NOTICE TO APPLI ANT If after making t Is Certificate of VENTILATION SYSTEM FINAL
Exemption you should become subject to the Workers
Compensation provisions of the Labor Code you must forth EVAPORATIVE COOLER VALIDATION
with comply with such provisions or this permit shall be
deemed revoked FURNACE FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED—UNIT—
(commencing
USPENDED UNIT(commencing with Section 7000) of Division 3 of the Business HEATER WALL
and Professions Code and my license Is In full force and effect
License Number Llc Class , V
Contractor Date 0
❑ I am exempt under Sec V
Plan check fee IL
B&P C for this reason fA
Date PERMIT ISSUING FEE; 'V Z
Signature TOTAL FEE
OWNER BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor s License
Law for the following reason (Section 7031 5 Business and NAME , ,+
PProfessions Code) -
/l� I as owner of the property or my employees with ADDRESS ti I r
wages as their sole compensation will clothe work and
CITY TEL NO
the structure Is not Intended or offered for sole(Section -`�7 �Il cILI
7044 Business and Professions Code) OWNER
❑ I as owner of the property am exclusively contracting MAIL Y t
with licensed contractors to construct the project (Sec ADDRESS il1TAL 20.50
tion 7044 Business and Professions Code)
CONSTRUCTION LENDING AGENCYCITY `p TEL 2B.Z 1H 2`0 51
1 hereby affirm that there Is a construction lending agency for , t LJPA*z W
the performance of the work for which this permit is Issued CONTRACTOR
(Sec 3097 Civ C )
ADDRESS
Lenders Namel,l�i[�—,fi� i iJ�11�r7
Lender s Address CITY TEL NO IF4 i AM 1
0 ci2
I certifythat I have read this application and state that the STATE LIC 1 1 n11
PP LICENSE NO CLASS
above 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 thea ove mentioned roperty for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
S gnature of ppl VAt o Agent Date