HomeMy Public PortalAbout5219 FARAGO AVE_Mechanical__ ION
WOthat I have
a certificate
of consent to 76A346DPW9/89 APPLICATION FOR PERMIT LIME GREEN
76A364C
I hereby'8ffirtt� that I have a certificate of consent to self insure,
or -ce't,4cate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING
copy thereof(Sec. 3800 Lab. C.).
Policy NO: Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND'SAFETY DIV.
❑ Certified copy is hereby furnished.
❑ Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN BBUoRess
department. (PRINT OR TYPE ONLY) `
LOCALITY
Date Applicant
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEARESTG^r( ll
h
COMPENSATION INSURANCE CROSS
ABSORPTION UNIT,BTU ASSESSOROR
(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.)
DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to I BOILER,BTU
become subject to the Workers'Compensation Laws.
COMPRESSOR,BTU
Date f Applicant APPROVALS DATE INSPECTOR'S SIGNATURE
PP VENTILATION SYSTEM
NOT CE TO AP (CANT: If, after making this Certificate of ROUGH
Exemption, you should become subject to the Workers' Compensation EVAPORATIVE COOLER 7
provisions of the Labor Code, you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION, FLOOR BTU / YJV VALIDATION
1 hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT
(commencing with Section 7000) of Division 3 of the Business and HEATER: WALL
Professions Code,and my license is in full force and effect.
License Number Lic.Class 4)" -0 0
Contractor ��b,Z� Date d
El am exempt under Sec. Plan Check fee
B.&P.C.for this reason PERMIT ISSUING FEE $ O
f—
Date: TOTAL FEE V
W
Signature 0-
PLAN CHECK APPLICANT U)
OWNER-BUILDER DECLARATION Z
I hereby affirm that I am exempt from the Contractor's License Law NAME -.
for the following reason (Section 7031.5, Business and Professions %v
Code): ADDRESS
❑ I, as owner of the property, or my employees with wages H.-CT.
as their sole compensation, will do the work and the CITY TEL.NO. ;a L�[�P 41_`r _t;°'s(:
structure is not intended or offered for sale (Section 7044,
Business and Professions Code). OWNER L °s 1T—
❑ I, as owner of the property, am exclusively contracting ; a-=7
MAIL _ .f I 1(-IL -_3 as 00
with licensed contractors to construct the project (Sec- ADDRESSli Lr,:
tion 7044, Business and Professions Code). - •I•;L'•:rY. :37°Ori
CITY �/ TEL.NO.
CONSTRUCTION LENDING AGENCY _ °F.iY -
hereby affirm that there is a construction lending agency for '<'I_�i
, INGE
the performance of the work for which this permit Is issued CONTRACTOR
(Sec. 3097,Civ.C.).
ADDRESS /J ----
e G L III.-J 'J`II`I i
Lender's Nam
CITY
,L w
r. TEL.NO / , 60.1
Lender's Address STATE LIC. �A
I certify that I have read this application and state that the above LICENSE NO. 7 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
pro�pertfDiinspect& purpose SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATURE OF A;rCANTrGENr DTE