HomeMy Public PortalAbout5203 FARAGO AVE_Mechanical__ r� W COMPENSATION DECLARATION APPLICATION FOR PERMIT
I ptreby affirmirm that I have a certificate of consent to self `
Insure or a certificate of Workers Compensation Insurance 76A364C HEATING VENTILATING AIR CONDITIONING
or a certified copy thereof (Sec 3800 Lob
)
/'3 11
? Q� [.� CE 818(REV 10/81)
Policy No�1 -Iompany `T t � t `N `
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 departm�Je/W f (PRINT OR TYPE ONLY) ADDRESS
Date (r Applicant ' I t / NO TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS NEAREST rl I
COMPENSATION INSURANCE CROSS ST 2
r2
(This section need not be completed If the work Involved by ABSORPTION UNIT BTU DISTRICT NO PROCESSED BY
the permit Is for one hundred dollars (;100)or less )
AIR HANDLING UNIT CFM
I certify that in the performance of the work for which this
permit is issued I shall not employ any person in any manner BOILER BTU
so as to become subject to the Workers Compensation Laws 1� APPROVALS DATE INSPE OR S SIGNATURE
Date Applicant COMPRESSOR BTU v a ROUGH
NOTICETO 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 1 VAI IDA (ON
with comply with such provisions or this permit shall be
deemed revoked FURNACE FAU GRAVITY 0
-LICENSED CONTRACTORS DECLARATION 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 WALL
and Professions Code and my license is In full force and effect CL
-*F? s -1T QTS 0 �7J d
License Number c' K bD N u Llc Class C —Z ( V
/ OC
Contractor 71 'r� Date 0 0
❑ I am exempt under Sec _ W
Plan check fee H
B&P C for this reason PERMIT ISSUING FEE $ V z
Date '
Signature TOTAL FEE
OWNER BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor s License ;29226A
Law for the following reason (Section 7031 5 Business and NAME
Professions Code) _ # • • o -1- 8
❑ I as owner of the property or my employees with ADDRESS ( e • 4 1 Q 0
wages as their sole compensation will do the work and CITY TEL NOo e o () x
the structure is not Intended or offered for sale(Section 0
7044 Business and Professions Code) OWNER
❑ I as owner of the property am exclusively contracting 5 10322-88
with licensed contractors to construct the project (Sec MAIL
tion 7044 Business and Professions Code) ADDRESS Q
CONSTRUCTION LENDING AGENCY CITY TEL-NO O
I hereby affirm that there Is a construction lending agency for
the performance of the work for which this permit Is Issued CONTRACTOR /'� —r/Q LN C. ,
(Sec 3097 Civ C )
ADDRESS
Lender s Name �/1
Lender s Address CITY ,y'�N r/ I _ TEL NO 3,57
,STATE I 1 (�� �y LIC
I certify that I have read this application and state that the LICENSE NO 5 liZ I CLASS C ( v —zo
above Information Is correct I agree to comply with all County
ordma ces and State laws relating to building construction
and eby authorr represen tives of this County to enter
up n e abov n d pr erty for Inspection purpose SEE REVERSE FOR EXPLANATORY LANGUAGE
Ignature of A plicant or Agent Date _ `