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HomeMy Public PortalAbout5215 FARAGO AVE_Mechanical__ WORKERS' COMPENSATION DECLARATION APPLICATION FOR PERMIT I hereby affirm that I have a certificate of consent to self insure, or a certifi;ate of Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING or a certified copy thereof (Sec. 3800 Lab C.) 76A364C Y Np�,�11s, � p y X46 DPW 9/88 Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY Eltion Certified copy is filed with the coup y building inspec- FOR APPLICANT TO FILL IN BUILDING A tion department. ADDRESS t / (PRINT OR TYPE ONLY) Date Applicant LOCALITY NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST COMPENSATION INSURANCE CROSS ST. BTU (This section need not be completed if the work involved by ABSORPTION UNIT, DISTRICT NO. PR ESSED BY the permit t war for one hundred dollars or less.) 0 ' I certify that in the performance of the work for which this AIR HANDLING UNIT, CFM o permit is issued, I shall not employ any person in any manner SO a5 t0 become subject 10 the Workers Compensation LOWS. BOILER, BTU - APPROVALS DATE INSPECTOR'S SIGNATURE COMPRESSOR, BTU P-0 0(,i'J� ROUGH Date Applicant 7 NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL A` Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER A I I� with comply with such provisions or this permit shall be deem- ed revoked. FURNACE: FAU—GRAVITY O� 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 Iic nse is in full force and effect. VttetT (J J"� >_License Number Lic. Class ✓ 0 Contractor to �{� 0 ❑ I am exempt under Sec. V Plan check fee B.&P.C. for this reason. H Date: PERMIT ISSUING FEE $ Z Signature TOTAL FEE '� 'OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT' I hereby affirm that I am exempt from the Contractor's License Poo.Law for the following reason (Section 7,031.5, Business and NAME Professions Code): I, as owner of the property, or my employees with ADDRESS ❑ wages as their sole compensation,will do the work andCC o� the structure is not intended or offered for sale(Section CITY TELNO. 7044, Business and Professions Code). s� OWNER 53.0 J ❑ I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec- MAIL �/ 1 ITEMS tion 7044, Business and Professions Code). ADDRESS ( tl AVE TOTAL 53_ CONSTRUCTION LENDING AGENCY CITY ,%b C 00 TEL. NO. �(g)Z�( g- I hereby affirm that there is a construction lending agency for c CHECK 53.00 the performance of the work for which this permit.-is issued CONTRACTOR �cL ` /� L , (Sec. 3097, Civ. C.). CHANGE .00 ADDRESS t vj�� Lender's Name � ' CITY TEL. NO. (�JQ r! i `? �� Lender's Address f d'� Z�( `�� 11100f'�-0001 ��d7/4T( STATE [` LIC. 1 75 ate! ?a t 1 certify that I have read this application and state that the LICENSE NO. )'� CLASS C � ? I,L'/_t 1 tilt ;=1� above 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 th above-mention d property for inTection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent Date r Os WORKERS' COMPENSATION DECLARATION APPLICATION FOR PERMIT I hereby affirm 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�c/o'py t �h er e of (Sec. 3800,, Lab. C.) y ti`� }r.� P Y �• , r./ - 1 4>J« 20-0046 DPW 9/88 Policy No. om an 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 �7 tion department. ADDRESS ,( (PRINT OR TYPE ONLY) Date Zi.` ) Applicant LOCALITY NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST COMPENSATION INSURANCE CROSS ST. (This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO. PROCESv the permit is for one hundred dollars ($100) or less.) / r� I certify that in the performance of the work for which this AIR HANDLING UNIT, CFM �f/1 l/O) permit is issued, I shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws. BOILER, BTU //''�' APPROVALS ATE SPECTOR'S SIGNATURE Applicant COMPRESSOR, BTU �,0 ROUGH Date ` 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 V L D with comply with such provisions or this permit shall be deem- ed revoked. FURNACE: FAUG VITY LICENSED CONTRACTORS DECLARATION FLOOR BTU I hereby affirm that I am licensed under provisions of Chapter 9 r 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. License Number t�h Lic. Class 1./ n w I , 0 Q (- n V Contractor <' Date U � OC El - I am exempt under Seca 0 Plan check fee B.&P.C. for this reason. d PERMIT ISSUING FEE $ V� Date: TOTAL FEE Z _ Signature OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT I hereby affirm that I am exempt from the Contractor's License , Law for the following reason (Section 7031.5, Business and NAME Professions Code): .-, ❑' ADDRESS 1, as owner of the property, or my employees with wages as their sole compensation, will do the work and ACCT.v the structure is not intended or offered for sale(Section CITY TEL. NO. 7044, Business and Professions Code). e r�^ ' �q 1 33137 51ieclo ❑ OWNER r5E> �1/F/ �rt /Qf`<<i „ I, as owner of the property, am exclusively contracting � I ITEMS with licensed contractors to construct theproject (Sec- MAIL �` t 1 n�V ��/� `1 i��� tion 7044, Business and Professions Code). ADDRESS ✓ G f� �S-� CONSTRUCTION LENDING AGENCY 0 1 hereby affirm that there is a construction lending agency for CITY - K.��� TEL. NC(('C7) - ��1 �.HEC 5'13o110 the performance of the work for which this permit is issued CONTRACTOR —D (�` �� �G , CHANGE 00 (Sec. 3097, Civ. C.). ' ADDRESS Lender's Name I '` 1� 1�1_{� 1 � n7 �_r CITY '�N ��Rt� TEL. NO. ��/2f 14 � C-C>. 000 4f.a r/:L+ Lender's Address 1 certifythat I have read this application and state that the STATE P p LIC. 1�3(` 1 AN 9:11 PP LICENSE NO. '�r,7 7� CLASS rz.�� above 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 U ��LZW'\— bove-m tinned property for inspection purposes. � r SEE REVERSE FOR EXPLANATORY LANGUAGE . h C/ Signature of Applicant or Agent Date ©s