HomeMy Public PortalAbout5117 FARAGO AVE_Mechanical__ ION
WORKER'S I have
a certificate
of consent to 76A346DPW9/89 APPLICATION FOR PERMIT LIME GREEN,
76A364C
I hereby affirm that I 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 Lab. C.) . "d
Policy No. 191-1�tl 6 ompany \U nil COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
❑ Certified copy is hereby furnished.
❑ Certified copy is filed with the count building inspection FOR APPLICANT TO FILL IN BUILDING �J
Y 9 P ADDRESSj� D ✓v
PRINT OR TYPE ONLY
d�� a ��`CJ�h,,;;)G ! ;I C C, LOCALITY i
Date Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE f/
NEAREST
CERTIFICATE OF EXEMPTION FROM WOR RS' CROSS ST.
COMPENSATION INSURANCE t;,—e. CA C'm ABSORPTION UNIT,BTU
(This section need not be completed if the work involved by the ASSESSOR
MAP QPARCEL
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit �p
is issued, I shall not employ any person in any manner so as to BOILER,BTU �jt [%��
become subject to the Workers' Compensation Laws. CC/f�n_ ✓ /1� -t t�n
/rll /�s ,^ COMPRESSOR,BTU U
Date V !,Applicant �• �•- C-W VENTILATION SYSTEM -APPRovALs DATE wsPEcroR•ssIGNATURE
NOTICE TO APPLICANT: If, after making this Certificate of" ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL O 31
provisions or this permit shall be deemed revoked. 1 FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION 1 FLOOR BTU � 'V G ✓ VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
(commencing with Section 7000) of Division 3 of the Business and WALL
Professions Code, and my license is in full force and effect.
^ O _y-
License Number Lic.Class
Contractor s� aVi'P �tf`�YtOt Data t 1 !� J 1 Cil D ,
❑ I Plan check fee U
am exempt under Sec. �
B.&P.C.for this reason PERMIT ISSUING FEE$ 0
Date: TOTAL FEE W
CL
Signature
PLAN CHECK APPLICANT h
OW BUILDER DEC ATION ACCT Z
I hereby affirm that 1 am exempt from t Contractor's License Law NAME109-1
't CC
for the following reason (Section 7031.5, Business and Professions , ",'.0 109 -1'�
Code): ADDRESS❑ {{ TTTEM i 1 i Gi i•J
I, as owner of the property, or my employees with wages ♦' i1 �4
as their sole compensation, will do the work and the CITY TEL.NO. TOTALio9 ® 55
structure is not intended or offered for sale (Section 7044,
tt�� (� CHECK 1109.55
Business and Professions Code). OWNER < 15 1� •(1 `�T vo t,•f ECK
❑ I, as owner of the property, am exclusively contracting MAIL J ' ` `^ \l ` ti: � ,r� ,lfl
with licensed contractors to construct the project (Sec- ADDRESS rj C , TJOC"C'j�
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY �/t R L.NO. �G 8120119,21
y -}�t19 L
LJ\ V
I hereby affirm that there is a construction lending agency for CONTRACTOR 0000-0001 1201
the performance of the work,for which this permit Is issued R'}�(�p�jG �o JG C���
(Sec. 3097,Civ. C.). , 5117 1 AN 9aI 9
ADDRESS 1 f- CA Av 'VC
C YO 9
Lender's Name Y
CITY TEL.NO./�
Lender Address PP STATE l�`� CLASS V d�
I certify that I have read this application and state that the above LICENSE NO.
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 inspect; n purposes 1 (� SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATURE OF APPLI N OR AGENT DATE