HomeMy Public PortalAbout5119 FARAGO AVE_Mechanical__ WORKER'S COMPENSATION DECLARATION 20-0046 DPW 9/89 APPLICATION FOR PERMIT LANE GREEN,
1 kereby affirm that I have a certificate of consent to self insure, 76AWAC
or a certificate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING=AIR CONDITIONING
copy thereof(Sec.3800 L b. C.) LI
Policy No. Company NO COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
Certified copy is hereby furnished.
�d JI Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN BUILDING ���
/ 'department. / (PRINT OR TYPE ONLY) ADDRESS,—ii TU G{T►�
Date Applicant . r � NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY /W
4WJ
�Q CROSSNEARES T. .CT/�I
CERTIFICATE OF EXEMPTION FROM W KE S'
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($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit �
is issued, I shall not employ any person in any manner so as to BOILER,BTU y
become subject to the Workers'Compensation Laws. / Jx,
COMPRESSOR,BTU
APPROVALS DATE INSPECTOR'S SIGNATURE
DateIff— Applicant VENTILATION SYSTEM
NOTICE TO APP ICANT: If, after making this Certificatt of ROUGH '
Exemption,you sh6uld become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU_qJWVITY ,�L
LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATION
1 hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT
(commencing with Section 7000) of Division 3 of the Business and HEATER: WALL
Professions Code, and my license is in full force and effect.
D C�
License Number f9 �d't0 Lic.Class 6f c2
Contractor /"ry Date , 0
❑ I am exempt under Sec. Plan CheCk fee
B.&P.C.for this reason PERMIT ISSUING FEE$ 1 0
Date: TOTAL FEE �� t ll
Signature
PLAN CHECK APPLICANT W
OWNER-BUILDER DECLARATION vt
I hereby affirm that I am exempt from the Contractor's License Law NAME
ITEM
for the following reason (Section 7031.5, Business and Professions , ACC `4 1_
Code): ADDRESS {?TL I O
El1, as owner of the property, or my employees with wages n
as their sole compensation, will do the work and the CITY TEL.NO. CHECK 109.55 .
structure is not intended or offered for sale (Section 7044, CHANGE
Business and Professions Code). OWNER ' /a�� s CHANGE .00
❑ I, as owner of the property, am exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRESS '! 0000—
O�/tion 7044, Business and Professions Code). � .t0001 8/20/92
CONSTRUCTION LENDING AGENCY CITY /a TEL.NO. ' 5116 " 1 AIS d 09I hereby affirm that there is a construction lending agency for CONTRACTOR �j/)
the performance of the work for which this permit is issued ( ,
(Sec.3097,Civ. C.):
ADDRESS s L�
Lender's Name Q
CITY lid&S� TEL.NO. ^�
Lender's Address STATE LIC.
I certify that I have read this application and State that the above ' LICENSE NO. vav CLASS
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 ' spection pu es. SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATURE O PLICANT OR AGENT - DATE