HomeMy Public PortalAbout5113 FARAGO AVE_Mechanical__ ION
DECLARATI
WORKER,have aENSATate of consent to 76A346DPW9/89 APPLICATION FOR PERMIT LIME GREEN.
76A364C
I herelay affirm that [,have a certificate of consent to self insure,
or a certificate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING -AIR CONDITIONING
copy thereof(Sec.3800 L9"
a C.)
Policy No. vCom panyY� AJI� COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
❑ Certified copy is hereby furnished.
Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN ADDR SS /
department. t (PRINT OR TYPE ONLY) �� N
Date r� Applicant G `� LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
NEAREST \
CERTIFICATE OF EXEMPTION FROM WOflKE CROSS ST.
COMPENSATION INSURANCE ABSORPTION UNIT,BTU
(This section need not be completed if the work involved by the ASSESSOR
MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU a
become subject to the Workers'Compensation Laws. Ly
COMPRESSOR,BTU I onO
APPROVALS DATE INSPECTOR'S SIGNATURE
Date' 11,A-Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, afte aking this Certifi to of ROUGH. �� � -
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU ' VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT
(commencing with Section 7000) of Division 3 of the Business and HEATER: WALL
Professions Code,and my license is in full force and effect.
License Number 6t Lic.ClassCL
Contractor N Date V Z , 0
I am exempt under Sec.
Plan check fee 0
BAP.C.for this reason PERMIT ISSUING FEE 0
H
Date: TOTAL FEE W
Signature OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT (n
Z
I he affirm that I am exempt from the Contractor's License Law NAME
for the following reason (Section 7031.5, Business and Professions , v
Code): ADDRESS ACCT.
u!
❑ I, as owner of the property, or my employees with wages
as their sole compensation, will do the work and the CITY TEL.NO. 3307 109.55
structure is not intended or offered for sale (Section 7044, q _TEMrMr.
❑
Business and Professions Code). OWNER M 1 .3 Mas GC. 1
I, as owner of the property, am exclusively contracting MAIL TOTAL 109_ ,e
with licensed contractors to construct the project (Sec- ADDRESS S v �/
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY &eA_6 1'JeEL.NO. 30U,�Qvav CHECK `�
Y f09� �p , CHANGE .00
the performance of the work for which this permit Is issued
(Sec.3097,Civ.C.).
ADDRESS 5g) _ zo �t�yt� �y�if� �.
Lender's Name 7 0000)--0001 i 8/20/:�t.2
/24(STEL.N0.2�� Ld 5119 1 AM 7�21�
Lender's Address J -�r/
I certify that I have read this application and state that the above LICENSE NO. CLASS C-�3-0
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 f i pection/pprposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATUR F APPLICANT OR AGENT_U DATE