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Home My Public Portal About5101 - 5107 FARAGO AVE_Mechanical__ WORKERS,that I have -a certificate DECLARATION APPLICATION FOR PERMIT rl hero��y.affirm that I have a certificate of consent to self . insure, or a certificate of Workers' Compensation Insurance, 76A364C HEATING - VENTILATING - AIR CONDITIONING or a certified copy thereof (Sec. 3800, Lab. C.) CE-818(REV. 10/81) Policy No. Company 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 / tion ep rtment. ADDRESS ,� �/ " O� Cly (PRINT OR TYPE ONLY) Date L' 4!AZ Applicant LOCALITY -7-04,0&6 0&6 W CERTIFICATE OF EXEMPTION FROM ORK S' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE NEAREST COMPENSATION INSURANCE CROSS ST. �/ 6c•e, (This section need not be completed if the work involV�d ABSORPTION UNIT, BTU DISTRICT NO. PROCESSED BY the permit is for one hundred dollars ($100)or less.) AIR HANDLING UNIT, CFM �` p I certify that in the performance of the work for which this � va permit is issued, I shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws. BOILER, BTU APPROVALS D rE PE OR'S SIGNATURE Date Applicant COMPRESSOR, BTU ROUGH NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER L I D-A T146N with comply with such provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY LICENSED CONTRACTORS DECLARATION 2 FLOOR BTU I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED 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 Lic. Class k) Contractor Date O I am exempt under Sec. a 8.8P.C. for this reason' Plan check fee �8 3 1.LLA � U Date: PERMIT ISSUING FEE # 0 0 0 0 0 8 Signature TOTAL FEE OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT I o 0 30, 50 1 hereby affirm that I am exempt from the Contractor's License Law for the followingreason Section 7031.5, Business and NAME tt � /� Z = Professions Code): ( Pat- Mc6n ti"� 0 0 0 3 0, 5 Q r� I, as owner of the property, or 'my employees with ADDRESS 5105-&3 dl�W20160 I t Q 6 i 8 7 wages as their sole compensation,will do the work and 7��n` ; the structure is not intended or offered for sale(Section CITY YL G TEL. NO. 7044, Business and Professions Code). ` � OWNER �G�� ❑ I, as owner of the property, am exclusively contracting rev with licensed contractors to construct the project (Sec- MAIL l !�`�� O�Jjj� tion 7044, Business and Professions Code). ADDRESS 4jL"S CONSTRUCTION LENDING AGENCY CITY /J-rZeab jl�_ TEL. NO.3,5,5—L�Q 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, Civ. C.). Lender's Name ADDRESS y�/�[�y� 2 J CITY ��7-�!✓1/1 TEL. NO.cJ�� Lender's Address v— STATE LIC. I certify that I have read this application and state that the 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 the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applica. t orgen Date WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT ^I hereby,affi•rm that I have.a certificate of consent to self insure, or a certificate of Workers' Compensation Insurance, 7oA3o4C HEATING - VENTILATING - AIR CONDITIONING i or a certified copy thereof (Sec. 3800,Lab. C.) CE-818(REV. 10/81) Policy No. Company 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 i r� tion ep rtment. ADDRESS �/��r G (PRINT OR TYPE ONLY) // Date !� lO' Applicant tt = LOCALITY / ,�e/ NO. TYPE OF APPLIANCE OR EQUIPMENT FEE G�"�f� l.L Y CERTIFICATE OF EXEMPTION FROM WORKE NEAREST /72 COMPENSATION INSURANCE CROSS ST. (This section need not be completed if the work in olved by ABSORPTION UNIT, BTU DISTRICT N ' PROCESSED the permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT, CFM I certify That in the performance of the work for which this 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 I TOR'S SIGNATURE Date Applicant COMPRESSOR, BTU ROUGH NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDA N 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 HEATER: SUSPENDED UNIT (commencing with Section 7000) of Division 3 of the Business WALL � and Professions Code,.and my license is in full force and effect. License NumberLic. Class Poo. U 99 Contractor Date O ❑ �- I am exempt under Sec. LU Plan check fee i a. B.BP.C. for this reason' PERMIT ISSUING FEE $ z � Date: 8 3 1.5 A Signature TOTAL FEE # o ro o o o 8 OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT Jf/:e 6 k)� I hereby affirm that I am exempt from the Contractor's License � L 10 - 3050 Law for the following reason (Section 7031.5, Business and NAME P �/'f Professions Code): � 0 0 0 3 0,5 0 6: I, as owner of the property, or my employees with ADDRESS �� .�� A60 wages as their sole compensation,will do the work and `7t�L�� ) 1, 06 -87 the structure is not intended or offered for sale(Section CITY TEL. NO. 7044, Business and Professions Code). n� 'V� L El 1, as owner of the property, am exclusively contracting OWNER I of A-) with licensed contractors to construct the project (Sec- MAIL �17 tion 7044, Business and Professions Code). ADDRESS L7lL�I' CONSTRUCTION LENDING AGENCY CITY �-i � TEL. NO.c:J,`- J,.�, I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued CONTRACTOR `S f ► (Sec. 3097, Civ. C.). ADDRESS Lender's Name Lender's Address CITY }�/�1/J,�g� Y TEL. NO. S�C�i�� STATE LIC. I certify that I have read this application and state that the 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 ttupoon�n t e above-mentioned property for insp cti n purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE 022, ®t�12� r/ fo Signature of Applica or ent Date