HomeMy Public PortalAbout5120 FARAGO AVE_Mechanical__ WORKER'S COMPENSATION DECLARATION 20.0046 DPW 9/89 APPLICATION FOR PERMIT LIME GREEN.,
76A364C
i�.7 rtty affir'fi that I have a certificate of consent to self insure, [�
o tificate of Worker's Compensation Insurance, or a certified HEATING -VENTILATIfid¢ -AA CONDITIONING
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copy thereof(Sec. 3800 Lab. C.) Ll
Policy No. Company COUNTY OF LOS ANGELES ' DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
Certified copy is hereby furnished.
❑ copy y g inspection FOR APPLICANT TO FILL IN BUILDING ^�
Certified co Is filed with the count building ADDRESS dQ [ QV G< 6(V9—
department.
(PRINT OR TYPE ONLY)
Date Applicant LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE Lei
001-
CERTIFICATE OF EXEMPTION FROM WORKERS' CNEAREROSS ST ST. free rCOMPENSATION INSURANCE ABSORPTION UNIT,BTU
(This section need not be completed if the work involved by the ASSESSOR
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permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
DISTRICBTDOK NO. P
RAG SSED BV PARCEL
1 certify that in the performance of the work for which this,permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU
O�become subject to the Workers' Compensation Laws. u
.� COMPRESSOR,BTU l `
//(.� APPROVALS DATE INSPECTOR'S SIGNATURE
Date 9� D—7 / Applicant �� <' VENTILATION SYSTEM
NOTICE TO APPLICANT: If, aft r making this Cert' ' to of ROUGH
Exemption,you should become subject to the Workers' pensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL f
provisions or this permit shall be deemed revoked. FURNACE: FAU GR VITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT
(commencing with Section 7000) of Division 3 of the Business and HEATER: WALL
Professions Code,and my license is in full crce and ffect.
65 0 176 C�[ c� C-l0
License Number / Lic.Cla�
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Contractor � fv& Date 120-0` 0
❑ I am exempt under Sec. Plan Check fee 1 it '_-? ,a
e.&P.C.for this reason PERMIT ISSUING FEE$
Date: TOTAL FEE 'J O "' `` W
Signature t s- j, 7 = 7I� a-
PLAN CHECK APPLICANT V)
OWNER-BUILDER DECLARATION `C.�-�rtj.•. -r^±� '{� Z
I hereby affirm that I am exempt from the Contractor's License Law NAME
for the following reason (Section 7031.5, Business and Professions
Code): ADDRESS
❑ I, as owner of the property, or my employees with wages
as their sole compensation, will do the work and the CITY TEL.NO.
structure is not intended or offered for sale (Section 7044,
Business and Professions Code). WNER - YI '_I a ,r;
1, as owner'of the property, am exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRESS -5 120 FC[)-6t Q 0—
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY Teva le- C( � TEL.NO.($z$)
I T. - 1'eG�hereby affirm that there is a construction lending agency for .NTRACTOR i 9h 00
,
the performance of the work for which this permit_Is issued
(Sec. 3097,Civ.C.).
ADDRESS 5 z D u o T2 rd
Lender's Name TEL.NO.C$18)30 5—:2a
Mo�'1r6V`a.
Lender's Address CITY
I certify that I have read this application and state that the above LICENSE NO. 6S q6 CLASS-(-to/ (--)_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
proper y r inspection�purposes.
, SEE REVERSE FOR EXPLANATORY LANGUAGE
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SIGNATURE OF APPLICANT OR AGENT DAT /