HomeMy Public PortalAbout5135 FARAGO AVE_Mechanical__ •<� • K' 76.11364C
r- ' bYO: ERS'C'Oh1,`,NSA-f IOL DECLARATION CE-818 (2-80) Q p p L ICS QT I O N FOR PERMIT
.I-hereby t firm that i :lavc a' c.- ti-icz:e-of consent to self
in-ure,or a certificate of Worker;'Compensation Insurance,or HEATING-VENTILATING-AOR
a certified copy thereof(Sec. 3900, Lab. C-�.)?} {
Policy"No _ 9I Company + 1`��"f�.t�l"�^L
❑ Certified copy is hereby furnished.
COUNTY OF LOS ANGELES BUILDING ARID SAFETY
Certified copy is filed with the county building inspection
de artme t. FOR APPLICANT TO FILL IN BUILDING �� ��
�� F (PRINT OR TYPE ONLY) ADDRESS
Date_ Applicant �'�J'/��(�/���(//j `
LOCALITY � Y
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE i�
COMPENSATION INSURANCE NEAREST
(This section need not be completed if the work involved I ABSORPTION UNIT, BTU CROSS ST. a
by the permit is for one hundred dollars ($100) or less.) DISTRICT NO. P ESS.D By O
�... .
I certify that in the performance of the work for which this, AIR HANDLING UNIT,CFM
permit is issued, I shall not employ any person in any manner 'I
so as to become subject to the Workers' Compensation Laws. �I BOILER, BTU O
APPROVALS DATE NSPFOTOR'S SIGNAT EU
Date Applicant COMPRESSOR, BTU 4 J GGA �( �(+J � I W
ROUGH
NOTICE TO APPLICANT: If, after making this Certificate of I VENTILATION SYSTEM FINAL Z _
Exemption, you should become subject to the Workers' - _
Compensation provisions of the Labor Code, you must forth- I EVAPORATIVE COOLER VALIDATION
with comply with such provisions or this permit shall be
deemed revolted. I FURNACE: FAU
BTU_ Gioo
LICENSED CONTRACTORS DECLARATION I `�" FLOG R;_ raj
I hereby affirm that I am licensed under provisions of Chapter HEATER: SUSPENDED UNIT
9 (commencing with Section 7000) of Division 3 of the Busi- WALL
ness and Professions Code, and my license is in full force and � `
effect. �j2 �N LIE: OLS' L_ �7p
License Number 06 Lie. Class e2.�
Contractor Date
❑ J1r2
� ` sI Iam exempt from the licensing reyuements as i a, a
licensed architect or a registered professional engineer ?fall Check fee 25%of above.
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code). I PEff$f1/ill'ISSUING FEE $/� S
Lie.or Reg.No. Date TOTAL FEE
SO
Sy.
HOME OWNER-BUILDER DECLARATION A PLAN CHECK APPLICANT
II �iwF•�a o
1 hereby affirm that I am exempt from' the Contractor's II NAME
License Law for the following reason (Section 7031.5, Busi- 3.� ( t.•f
ness and Professions Code): i ADDRESS ; ENE
-
structure
as owner of the property, will do the work and the
structure is not intended or offered for sale (Section CITY TEL. NO. .r.tDTA 146
sr �,,;0
7044, Business and Professions Code).
❑ j'owa NER �r�ISF_ mwLa A LENS (-I,E_;-K 14 9I
I, as owner of the property, am exclusively contracting uv
o C11-- t'l'.:o•.'.i
with licensed contractors to construct the project I ADDRESS c LI V 0^k ��C �",ihj _ III
(Section 7044, Business and Professions Code). i CIG
TEL.NO. �.7 I
CONSTRUCTION LENDING AGENCY ,� /�I�t� _� ^i.
1 hereby affirm that there is a construction lending agency �t�CE_,r,_ l (h_i y1 �, ,.7
for the performance of the work for which this permit is CONTRACTOR S�
issued (Sec. 3097,Civ.C.). € AN1 I`_=
Lender's Name I ADDRESS
l �
Lender's Address CITY G A t1 i Ar_+ 1ppl TEL.NO. 7QC1
I certify that I have read this application and state that the STATE (�"rJI�°2 i.i LIC. DLXi
above information is correct. I agree to comply with all County LLI_CENSE NO. � > CLASS
ordinances and State laws regulating Heating, Ventilating and --
Air Conditioning,and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE a
County to enter upon the above-mentioned property for
iuspe tion purposes.
Signature of Permittee Date j