HomeMy Public PortalAbout5201 FARAGO AVE_Mechanical__ \WORKERS COMPENSATION DECLARATION APPLICATION FOR PERMIT
affirm that I have a certificate of consent to self
Insure or a certificate of Workers Compensation Insurance L HEATING - VENTILATING AIR CONDITIONING
or a cert fled opy thereof (Sec 3800 Lab C ) 76A364C
L CE 818(REV 10/81)
Policy No �� Company �, �•` Futid
Certified copy is hereby furnished COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with the county building inspec FOR APPLICANT TO FILL IN BUILDING ��`.
tion department (PRINT OR TYPE ONLY) ADDRESS lJ
FJK J1 e7 0
Date Applicant 41 ^ '2d LOCALITY
NO TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS NEAREST
COMPENSATION INSURANCE CROSSST
PROCESSED BY
(This section need not be completed if the work involved by ABSORPTION UNIT BTU DISTRICT NO c/
the permit is for one hundred dollars ($100)or less) AIR HANDLING UNIT CFM x
I certify that in the performance of the work for which this /1�.�t/ (J
permit is Issued I shall not employ any person in any manner BOILER BTU
so as to become subject to the Workers Compensation Laws APPROVALS DATE INSP T S SIGNATURE
Date Applicant COMPRESSOR BTU 6da� ROUGH Q
NOTICE TO APPLICANT If after making this Certificate of VENTILATION SYSTEM FINAL
Exemption you should become subject to the Workers
Compensation provisions of the Labor Code you must forth EVAPORATIVE COOLER VALIDATI
with comply with such provisions or this permit shall be
deemed revoked FURNACE FAUGRAVITY '
LICENSED CONTRACTORS DECLARATION FLOOR BTU
Id
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER SUSPENDED—UNIT—
(commencing
USPENDED UNIT(commencing with Section 7000) of Division 3 of the Business WALL
and Professions Code and my license is in full force and effect
/u lvf O
License Number Llc Class C/0 V
Contractor -T Q Date / / ,
- o
F-1I am exempt under Sec d
Plan check fee H
B &P C for this reason PERMIT ISSUING FEE $ Z
Date �9756A
Signature TOTAL FEE
OWNER BUILDER DECLARATION PLAN CHECK APPLICANT # o o e e o 8
j hereby affirm that I am exempt from the Contractor s License ! , • - 4275
Law for the following reason (Section 7031 5 Business and NAME
Professions Code)
❑ I as owner of the property or my employees with ADDRESS • • ° 427506
wages as their sole compensation will do the work and CITY TEL NO 0 602-88
the structure is not intended or offered for sale(Section
7044 Business❑ and,Professions Code) OWNER G,5 N �C
I as owner of the property am exclusively contracting _
with licensed contractors to construct the project (Sec MAIL O '
tion 7044 Business and Professions Code) ADDRESS
CONSTRUCTION LENDING AGENCY CITY"'r4r, 1 TEL NOS �61 L�
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued CONTRACTOR - ,
(Sec 3097 Civ C )
ADDRESS
Lender s Name '
CITY Nl D TEL NO 3 S7
Lender s Address 53
It
STATE ¢ LIC4 /T —2�
I certify that I have read this application and state that the LICENSE NO �(J 2 CLASS (/ '�
above Information Is correct I agree to comply with all County
ordinances and State jaws relating to building construction
and he eby authorize repre ntatives of this County to enter
upo a ab ve entioned roperty for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
Z � i
Ignature Applicant or Agent Date