HomeMy Public PortalAbout5121 FARAGO AVE_Mechanical__ WORKER'S COMPENSATION DECLARATION zo-DD46DPW 9/69 APPLICATION FOR PERMIT L, E GREEN
76A364C
I hereby affirrmthat 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.) 1
Policy No.T)H (0�1 5 Ompany S CG-�c ����. COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
❑ Certified copy is hereby furnished.
I Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN BUILDING
/
/, department. i A (PRINT OR TYPE ONLY)
Q"/ rr{{ ' �n 11 G -1 `+�S LOCALITY
Date `� kV I q� Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE 1
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST y / h
COMPENSATION INSURANCE CROSS ST.
ABSORPTION UNIT,BTU ASSESSOR
(This section need not be completed if the work involved by the MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
I certify that in the performance of the worDISTRICT NO. PROCESSED BY
K for which this permit "
is issued, I shall not employ any person in any manner so as to BOILER,BTU
become subject to,the Workers'.Compensation Laws.
4COMPRESSOR,BTU G�
p. (�*�-e C�/1-ti•�/a APPROVALS DATE INSPECTOR'S SIGNATURE
Date 6 �����Applicant N �!�•� YJJ1 VENTILATION SYSTEM-
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
provisions or this permit shall be deemed revoked, FURNACE:. FAU G AVITv �{ VALIDATION
LICENSED CONTRACTORS DECLARATION 7 FLOOR BTU ✓
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.
r /� � d
License Number 62 1 G Lic.Class
Contractor GYl e C C'1 C�Y)t ate , }
❑ Lam exempt under Sec. Plan Check fee O
B.&P.C.for this reason PERMIT ISSUING FEE -70
O
Date: TOTAL FEE W
Signatu 0 14 PLAN CHECK APPLICANT. d
OWNV_ UILDER DECL ATI6N Z
I hereby affirm that I am exempt from the Contractor's License Law NAME , a'stj? 109.°5 �
for the following,"reas_on (Section 7031,5, Business and Professions TT f M
Code): '• - ADDRESS 1 1 1 Ef int _
I, as owner of the property, or my employees with wages TOTAL 109 .55
as their sole compensation, will do the work and the CITY TEL.NO.
TOTAL
structure is not intended or offered for sale (Section 7044, CHECK
Business and Professions Code). OWNER u I`
❑ I, as owner of the property, am exclusively contracting MAIL r CHANGE o►�I-�,
� h/�
with licensed co`ntractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY ¢ TEL.NO.
tC_
I hereby affirm that there is e"-construction lending agency for C '
the performance of the work for which this permit Is issued CONTRACTOR fv/-ice-� �}_ i AM
�aI}
(SeC.3097,Civ. C.). /`�/� G ,, 1 t ti
ADDRESS.
Lender's Nam 45 0-05
CITY t/ L XEL.NO.
Lender's Address STATE K LIC.
I certify that I have read this application and state that the above LICENSE NO. ` 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 inspection purp es. SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATURE 0 PrrCANT OR AGEN DATE