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HomeMy Public PortalAbout5116 FARAGO AVE_Mechanical__ WORKERS' COMPENSATION DECLARATION APPLICATION FOR PERMIT I hereby affirm that I have a certificate of consent to self nsure, or a certificate of Workers' Compensation Insurance, a , HEATING - VENTILATING - AIR CONDITIONING &a certified copy thereof (Sec. 3800, Lab. C.) 76A364C 20-0046 DPW 9/88 a- 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 department. (PRINT OR TYPE ONLY) ADDRESS Date Applicant LOCALITY NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST COMPENSATION INSURANCE CROSS ST. �y/�� (This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO. PROC D BY 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 so as to become subject to the Workers'Compensation Laws. IBOILER, BTU APPROVALS DAT INSPECTOR'S SIGNATURE / COMPRESSOR, BTU 30 111 ROUGH Date Applicant O / 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 VALIDATION with comply with such provisions or this permit shall be deem- 1j ed revoked. FLOOR FURNACE: FAU GRAVITY BTU O� LICENSED CONTRACTORS DECLARATION �� / I hereby affirm that l am licensed under provisions of Chapter 9 SUSPENDED UNIT_ /�\✓ 1 (commencing with Section 7000)of Division 3 of the Business HEATER: WALL. (J and Professions Code,and my license is in full force and effect. / 1 f License Number Lic. Class , Contractor Date ❑ 1 am exempt under Sec. Plan check fee u LU B.&P.C. for this reason. PERMIT ISSUING FEE $ tA Date: 2 TOTAL FEE Signature 13 Q OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT I hereby affirm that I am exempt from the Contractor's License Low or the following reason (Section 7031.5, Business and NAME Pro ssions Code): ADDRESS til._ n i :=:s; I, as owner of the property, or my employees with wages as their sole compensation, will do the work and 1 ITEMS the structure is not intended or offered for sale (Section CITY -. TEL. NO. 7044, Business and Professions Code). TOTAL 30 50 OWNER I, as owner of the property, am exclusively contracting350.50 with licensed contractors to construct the project (Sec- MAIL CASH H tion 7044, Business and Professions Code). ADDRESS tlA {3E nE(I'j 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 CONTRACTOR 00,(Sec. 3097, Civ. C.). 0000-000 1 11/::7J89 ADDRESS .11 139! 'Elt 1 AMq{e{1L ' Lender's Name J CITY TEL. NO. Lender's Address I certifythat I have read this application and state that the STATE LIC. 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 autgn ' representatives of this County to enter u n The abovtioned pLvale_roperty for ins a tion o es. i % SEE REVERSE FOR EXPLANATORY LANGUAGE ure oft ant or Agent Dat ©s